<U^ 


DR.  HENRY  REDMOND; 

1224  WALNUT  STREET, 

PHILADELPHIA,  PA, 


THE 


EYE 


Bt 

\J/ 

LTIDWIG   MAUTHNEK,  M.D 

YAL  PEOFESSOB  IN   THE  TINIVERSITY  OP 


TRANSLATED  FROM  THE  GERMAN 

fly 
WARREN  WEBSTER,   M.D. 

BURGEON,  UNITED  STATES   AliMT 
AND 

JAMES  A.  SPALDIKG,  M.D. 

MEMBER    OF  THE  AMERICAN  OPHTHALMOLOOtCAt  SOCIETY  J   OPHTHALMIC  SCB- 
OEON  TO  THE  MAINE  GENERAL  HOSPITAL. 


NEW  YORK 
WILLIAM    WOOD    &    COMPANY 

1881 


ranriivi          ,ftunc 


TRANSLATORS'    PREFACE. 


THIS  comprehensive  monograph,  on  the  SYMPA- 
THETIC DISEASES  OF  THE  EYE,  is  the  first  of  a  series 
intended  to  embrace  the  whole  province  of  Ophthal- 
mology. The  author,  Dr.  Ludwig  Mauthner,  of 
Vienna,  a  well-known  specialist,  has  two  objects  in 
view  Tone,  to  compile,  for  the  ophthalmic  surgeon, 
the  widely  diverse  opinions  on  the  subjects  under 
discussion  ;  the  other,  to  enable  the  general  practi- 
tioner, and  the  student  in  ophthalmology,  to  gain  an 
insight  into  the  pathology,  and  especially  into  what 
should  be  the  practical  treatment,  of  the  more  im- 
portant diseases  of  the  eye. 

Although  the  number  of  learned,  conscientious, 
and  skilled  oculists  in  America  is  daily  increasing, 
yet  there  will  be  exigencies  in  civil  life,  as  well  as  in 
the  military  and  naval  service,  when  their  assistance 
cannot  be  obtained.  A  large  majority  of  patients 
affected  with  diseases  or  injuries  of  the  eye,  should, 
and  naturally  will,  turn  at  once  to  their  family  physi- 
cian for  advice.  The  latter,  with  this  monograph  at 
hand,  or  others  of  the  series  as  they  shall  appear,  will 


iv  TRANSLATORS'  PREFACE. 

be  enabled  immediately  to  judge  of  the  triviality  or 
of  the  serious  nature  of  the  case.  He  will  then  de- 
cide either  to  treat  it  himself,  according  to  the  latest 
light  which  scientific  research  and  experience,  as  set 
forth  in  books,  have  thrown  upon  it,  or  to  refer  it,  if 
haply  he  can,  to  a  trustworthy  specialist  for  more 
minute  treatment,  or  for  an  operation,  if  necessary. 

In  so  far  as  regards  the  subject  of  the  present 
monograph  (SYMPATHETIC  DISEASES  or  THE  EYE),  we 
may  truly  say  that  it  is  one  of  the  most  important 
with  which  the  oculist  is  ever  concerned.  Upon  his 
correct  judgment  will  generally  depend  the  future 
vision  of  the  patient.  Much  more  urgent,  therefore, 
must  be  the  necessity  for  general  practitioners  in  the 
country,  and  for  medical  officers  of  the  army  and 
navy,  to  have  at  hand  a  clear  and  reliable  descrip- 
tion of  the  multiform  symptoms,  and  the  treatment,  of 
Sympathetic  Ophthalmia,  so  that  they  may  at  once 
recognize  its  presence,  and  treat  it  from  the  outset 
appropriately  and  effectually.  Although  cases  of  this 
nature  are  comparatively  rare,  their  importance  is 
sufficiently  great  to  account  for  the  appearance  of  this 
excellent  work  in  an  English  version. 


WARREN  WEBSTER. 
JAMES  A.  SPALDING. 


PORTLAND,  MAINE,  September  1,  1881. 


AUTHOE'S 


THESE  "  Lectures  on  Ophthalmology  "  cannot  fully 
succeed  in  their  professed  object  of  popularizing, 
among  practitioners  of  general  medicine,  the  specialty 
to  which  the  author  belongs,  unless  he  assumes  that 
the  readers  have  but  slight  acquaintance  with  oph- 
thalmological  terminology.  He  regrets,  however,  that 
he  has  occasionally  been  obliged  to  overstep  the 
bounds  of  general  description,  and  to  adopt,  for  a 
time,  the  necessary  minutiae  of  his  specialty. 

MAUTHNER. 
VIENNA,  March  27,  1878. 


CONTENTS 


ETIOLOGY,     . 


PAOE 

9 


PRELIMINARY  REMARKS,        . 

SECTION  I. 

12 
ANATOMY, 


SECTION  II. 

.     17 


SECTION  III. 

.     5G 

PATHOLOGY, 

SECTION  IV. 

.  105 

PATHOGENY, 

SECTION  V. 

146 

THERAPEUTICS,     , 

INDEX, 

•  209 

THE 


SYMPATHETIC  DISEASES  OF  THE  EYE. 


IT  is  a  terrible  thing  when  some  constitutional  dis- 
ease, or  a  local  disease  outside  the  eye — perhaps  of 
the  brain — or  some  definite  disease  of  the  eye  itself,  or 
a  traumatic  agent,  destroys  the  sight  of  both  eyes  at 
once.  Then,  again,  it  is  lamentable  when  one  eye  is 
destroyed,  at  a  greater  or  less  interval  after  the  other, 
from  a  repetition  of  the  original  injury,  as  has  twice 
occurred  in  my  experience,  from  the  explosion  of  gun- 
powder, and  the  thrust  of  a  cow's  horn.  The  misfor- 
tune, however,  is  even  more  aggravated  when  the 
second  eye  is  totally  lost,  simply  from  some  disease  or 
injury  of  the  first  eye;  or  when  a  surgical  operation 
on  the  one  eye  not  only  fails  of  its  object,  but  subjects 
the  opposite  eye  to  serious  mischief  ;  or  when,  after  a 
successful  operation  on  one  eye,  wa  attempt  at  a  later 
date  to  gain  some  vision  for  the  other,  and  not  only 

find  that  the  second  eye  is  unimproved  by  the  attempt, 
1* 


10  SYMPATHETIC   DISEASES    OF   THE   EYE. 

but  also  that,  as  a  direct  consequence  of  the  last  opera- 
tion, the  sight  once  happily  restored  to  the  first  eye  is 
again  imperilled. 

"  Sympathetic  ophthalmia  "  is  a  general  term,  which 
serves  to  designate,  not  a  particular  affection,  but  a 
whole  series  of  ocular  lesions,  which  differ  from  one 
another  in  their  seat  and  manifestations,  but  always 
have  a  common  origin.  When  an  eye  is  laboring  un- 
der injury  or  disease,  it  frequently  happens  that  the 
other  eye,  which  has  hitherto  been  healthy,  becomes, 
after  a  certain  time,  and  without  apparent  cause,  the 
seat  of  various  functional  or  structural  disturbances. 
The  latter  are  called  sympathetic  affections,  and,  taken 
together,  constitute  sympathetic  ophthalmia.  Those 
diseases,  therefore,  which  are  superinduced  in  the 
second  eye,  upon  an  injury,  or  a  disease,  of  the  first 
eye,  and  which  can  be  traced  to  no  other  cause  than 
the  original  injury  or  disease,  are  regarded  as  sym- 
pathetic diseases. 

Hardly  any  other  province  of  ophthalmology  is  of 
more  practical  importance,  and  in  no  other  are  greater 
demands  made,  as  -well  on  the  personal  experience  of 
the  practitioner,  as  on  his  acquaintance  with  the  expe- 
rience of  others;  in  hardly  a  second  field  is  greater 
good  to  be  expected  from  treatment,  or  greater  evil 
from  neglect,  than  in  the  one  comprising  the  svmpa- 
thetic  diseases  of  the  eye.  Here  it  is  not  tlie  fate  of 
a  single  eye  that  is  at  stake,  but  the  question  that  ;il- 


SYMPATHETIC   DISEASES   OF   THE   EYE.  11 

most  always  confronts  us  is:  Shall  the  individual  suf- 
fer utter  loss  of  sight,  or  shall  the  vision  of  at  least  one 
eye  be  wholly,  or  in  part,  preserved  ? 

Before  describing  the  symptoms  of  sympathetic 
affections  of  the  eye,  and  their  treatment,  we  must 
notice  the  primary  injuries  and  diseases  of  the  eye 
which  most  commonly  excite  sympathetic  disturbances. 
First,  however,  it  will  be  well  to  refresh,  in  a  brief 
manner,  our  remembrance  of  the  anatomical  structure 
of  the  eyeball. 


SECTION    I. 


ANATOMY. 

THE  eyeball  is  composed  of  several  investing  tunics, 
as  well  as  of  fluid  and  solid  contents,  called  the  refract- 
ing media.  The  most  important  of  the  latter  is  the 
crystalline  lens,  which  is  a  double  convex  body,  situ- 
ated immediately  behind  the  pupil,  and  having  its 
axis  in  the  same  line  with  that  of  the  eyeball  itself. 
It  is  retained  in  its  position  chiefly  by  the  suspensory 
ligament  (zonula  Zinnii),  which  connects  its  periph- 
ery with  the  anterior  margin  of  the  retina.  The  sus- 
pensory ligament  is  also  attached  to  the  ciliary  body 
by  a  series  of  radiating  folds  or  plaitings,  into  which 
the  corresponding  ciliary  processes  are  received. 

The  vitreous  humor,  which  occupies  about  four- 
fifths  of  the  eyeball  posteriorly,  is  surrounded  by  the 
retina  as  far  forward  as  the  termination  of  the  latter, 
at  the  ora  serrata,  and  is  bounded,  in  front,  by  the  cil- 
iary body,  the  zonula  of  Zinn,  and  the  posterior  cap- 
sule of  the  lens. 

That  portion  of  the  cavity  of  the  eyeball  which  lies 
in  front  of  the  lens,  between  the  latter  and  the  cornea, 


ANATOMY.  13 

is  occupied  by  the  aqueous  humor.  This  space  is  di- 
vided into  the  anterior  and  posterior  chambers  by  the 
iris,  a  thin,  membranous  curtain,  hanging  vertically  in 
front  -of  the  lens,  and  perforated  by  the  pupil  for  the 
transmission  of  light.  The  iris  may  be  regarded  as  a 
process  of  the  choroid,  with  which  it  is  continuous, 
although  there  are  differences  of  structure  in  the  two 
membranes.  The  anterior  chamber  is  bounded  in 
front  by  the  cornea,  a  perfectly  transparent  tissue,  the 
innermost  layer  of  which  is  a  single  stratum  of  flat, 
epithelial  cells,  which  rest  on  the  membrane  of  Desce- 
met,  and  are  bathed  by  the  aqueous  humor.  The 
anterior  chamber  is  bounded  posteriorly  by  the  ciliary 
ligament  and  the  iris,  and  by  that  portion  of  the  an- 
terior capsule  of  the  lens  which  lies  free  in  the  pupil. 

At  the  place  where  the  periphery  of  the  cornea  is 
overlaid,  like  a  watch-glass,  by  the  free  edge  of  the 
sclerotica,  a  multitude  of  stiff  fibrillse  stretch  across, 
in  a  curved  direction,  from  the  inner  surface  of  the 
cornea  to  the  front  of  the  iris,  and  constitute  collect- 
ively the  ligamentum  pectinatum  iridis.  The  epithe- 
lial cells  covering  the  membrane  of  Deecemet  are 
continued  upon  the  ligamentum  pectinatum,  where 
they  form,  in  conjunction  witli  the  fibrillse  of  the 
latter,  a  cellular  plate,  which  separates  the  anterior 
chamber  from  the  ciliary  body. 

The  whole  posterior  surface  of  the  iris  does  not  lie 
directly  in  contact  with  the  anterior  capsule  of  the 


14  SYMPATHETIC   DISEASES   OF   THE    EYE. 

lens,  but  only  the  central  portion,  that  is  to  say,  the 
pupillary  border.  Hence,  as  the  iris  occupies  a  nearly 
level  plane,  its  periphery  is  separated  from  the  ante- 
rior convex  surface  of  the  lens,  and  the  space  known 
as  the  posterior  chamber  is  formed.  The  individual 
ciliary  processes  project  into  the  angle  of  the  posterior 
chamber,  in  the  region  of  the  sclerotica.  The  poste- 
rior chamber  is  bounded  in  front  by  the  iris,  with  its 
thick  covering  of  pigment ;  whilst  its  posterior  wall  is 
made  up  of  the  anterior  capsule  of  the  lens,  the  zonula 
of  Zinn,  and  the  ciliary  processes. 

Inasmuch  as  the  pupillary  margin  of  the  iris,  in  a 
healthy  eye,  moves  freely  over  the  anterior  capsule  of 
the  lens,  no  obstacle  exists  to  an  interchange  of  the 
fluid  contents  of  the  anterior  and  posterior  chambers  ; 
indeed,  if  the  pupil  be  dilated  by  the  instillation  of 
atropia,  so  that  the  border  of  the  pupil  can  no  longer 
touch  the  anterior  capsule,  the  two  chambers  become 
practically  blended  into  one. 

The  retina  is  a  delicate,  semi-transparent  expansion 
of  the  optic  nerve,  and  extends  nearly  as  far  forward 
as  the  ciliary  muscle,  where  it  terminates  by  a  jagged 
margin,  the  ora  serrata.  Its  outer  surface  lies  in  con- 
tact with  the  pigmentary  layer  of  the  choroid  ;  its 
inner  surface,  with  the  vitreous  body.  The  optic  nerve 
pierces  the  sclerotic  and  choroid  coats  at  the  back  part 
of  the  eyeball,  and  enters  its  cavity  at  a  spot  called  the 
optic  papilla  <  a  little  to  the  nasal  side  of  its  posterior 


ANATOMY.  15 

pole.  On  examining  the  concave  inner  surface  of  the 
retina,  we  observe,  directly  in  a  line  with  the  axis  of 
the  globe,  and  situated  about  three  millimetres  out- 
ward from  the  optic  papilla,  a  circular  .yellow  spot, 
which  presents  a  central  depression  (fovea  centralis), 
in  which  the  sense  of  vision  attains  its*  greatest  per- 
fection. A  horizontal  section  of  an  eyeball,  accurately 
dividing  the  optic  papilla  into  an  upper  and  a  lower 
half,  would  not  bisect  the  fovea  centralis,  which  lies  in 
a  plane  slightly  below  the  papilla. 

The  clioroid  is  the  vascular  membrane  of  the  eye, 
and,  with  the  ciliary  body  and  iris,  constitutes  the  uve- 
al  tract.  It  is  interposed  between  the  sclerotica  and 
the  retina,  and  is  thinner  than  either  of  these  tunics ; 
but  its  important  appendage,  the  ciliary  body,  which 
lies  next  to  it  in  front,  attains  a  considerable  size, 
being  about  four  millimetres  thick  from  before  back- 
ward. This  body — which  is  made  up  of  the  zonula  of 
Zinn,  the  ciliary  processes,  and  the  ciliary  muscle — -is 
divisible  into  two  parts :  the  inner  portion  consists  of 
the  zonula  and  the  ciliary  processes;  the  outer  por- 
tion (which  was  formerly  regarded  as  a  ligament,  but 
in  which  the  existence  of  muscular  fibres  has  been 
demonstrated  by  Briicke,  Bowman,  and  Miiller)  oc- 
cupies the  space  between  the  scleral  insertion  of  the 
cornea  and  the  periphery  of  the  iris.  The  ciliary  mus- 
cle is  united  externally  with  the  cornea  and  sclerotica, 
and,  internally,  merges  into  the  ciliary  processes  ;  be- 


16  SYMPATHETIC   DISEASES    OF   THE    EYE. 

hind,  it  is  continuous  with  the  choroid,  and,  in  front, 
is  inserted,  by  a  portion  of  its  fibres,  into  the  iris, 
whilst  by  others  it  is  attached  to  the  wall  of  the  canal 
of  Schlemm  and  to  the  ligamentum  peetinatuiu  iridis. 
The  contraction  of  the  ciliary  muscle  draws  the  cho- 
roid forward  9,nd  (by  aid  of  its  circular  fibres)  inward, 
toward  the  equator  of  the  lens. 

During  youthful  life,  or  so  long  as  the  lens  remains 
soft,  its  form  is  regulated  by  the  degree  of  tension 
maintained  in  its  capsule  by  the  suspensory  ligament. 
When  the  latter  is  relaxed,  by  the  action  of  the  ciliary 
muscle,  the  lens  retracts  by  its  own  elasticity,  and 
becomes  more  globular  in  shape,  thereby  increasing 
the  refractive  power  of  the  dioptric  apparatus  of  the 
eye.  In  a  word,  it  is  the  office  of  the  ciliary  muscle 
to  effect  that  adjustment  of  the  eye  (accommodation) 
for  near  and  remote  objects,  which  enables  it  to  pro- 
duce distinct  images  on  the  retina. 

If  we  pass  a  probe  from  the  outermost  edge  of  the 
anterior  chamber,  through  the  ligamentum  pectinatum 
iridis,  into  the  ciliary  body,  we  penetrate,  beneath  the 
cellular  plate,  a  coarse-meshed  net-work,  lined  with 
cells,  analogous  to  the  canal  of  fbntana,  as  found  in 
the  ox.  This  structure  is  to  be  distinguished  from  a 
circular  canal,  filled  with  venous  blood,  and  called  the 
canal  of  Schlemm,  which  is  tunnelled  out  of  the  scleral 
tissue,  around  the  margin  of  the  cornea,  and  resembles, 
in  places,  a  plexus  of  veins. 


SECTION    II. 


ETIOLOGY. 

THE  ciliary  body  is  copiously  supplied  with  nerves 
and  vessels,  and  may  be  called  the  dangerous  region 
of  the  eye — the  one  from  which  most  of  the  sympa- 
thetic affections  of  the  second  eye  proceed. 

The  diseases  of  the  ciliary  body  may  arise  either 
spontaneously  or  from  traumatic  causes.  The  asso- 
ciation of  a  wound  with  the  morbid  process  does  not 
necessarily  expose  the  second  eye  to  increased  danger. 
Nevertheless,  a  graver  danger  has  been  attached  to  the 
traumatic  affections  of  the  ciliary  body,  not  only  be- 
cause they  are  more  frequent  than  the  idiopathic,  but 
from  the  fact  that  when  a  foreign  body  remains  in  the 
eye  the  traumatic  affections  are  less  easily  controlled, 
or,  when  apparently  under  control,  are  more  readily 
rekindled.  Wounds  of  the  ciliary  body  should,  in- 
deed, excite  solicitude,  for  they  may,  at  longer  or 
shorter  intervals,  inflict  on  both  eyes  the  most  unfor- 
tunate consequences.  On  the  other  hand,  very  serious 
accidents  to  the  ciliary  body  have,  under  surgical 


18  SYMPATHETIC    DISEASES    OF   THE    EYE. 

treatment,  or  through  some  lucky  and  unforeseen  acci- 
dent, or  even  spontaneously,  terminated  in  the  recov- 
ery of  the  injured  eye,  without  the  implication  of  its 
fellow. 

A  patient  came  to  me  complaining  that  he  had  in- 
jured himself  at  smith- work,  and  that  a  piece  of  iron 
had  certainly  entered  his  eye.  A  small  wound  was 
visible  in  the  upper  and  outer  part  of  the  sclerotica, 
near  the  margin  of  the  cornea.  The  eye  wept,  showed 
slight  episcleral  injection  around  the  cornea,  and  was 
sensitive  to  pressure  at  the  wounded  spot.  A  more 
careful  examination  showed  that  the  lens  was  appar- 
ently clear  and  uninjured  ;  no  deeper  wound  nor  per- 
foratipn  of  the  anterior  chamber  could  be  discovered. 
It  was  possible,  however,  that  a  small  foreign  body 
had  penetrated  the  eyeball  and  still  remained  at  the 
bottom  of  the  wound.  Perhaps  it  was  lodged  in  the 
ciliary  body,  and,  in  that  case,  the  inflammation  ex- 
cited therein  (cyclitis)  might  endanger  both  the  in- 
jured and  the  sound  eye.  A  fine  bistouri,  introduced 
into  the  wound,  under  anaesthesia,  encountered  some 
metallic  body.  The  wound  was  at  once  enlarged,  and 
a  small  chip  of  iron  removed  with  delicate  forceps. 
All  the  signs  of  irritation  disappeared  with  exceeding 
rapidity,  the  wound  healed  in  a  few  days,  and  no  sen- 
sitiveness whatever  of  the  ciliary  body  remained. 

In  a  second  case,  the  patient  had  severely  wounded 
his  right  eye  while  discharging  a  musket.  He  avenvd. 


ETIOLOGY.  19 

with  the  utmost  confidence,  that  no  foreign  body  was 
lodged  in  the  eye.  But  it  was  evident  that  a  perfora- 
tion, located  in  the  centre  of  the  cornea,  had  been 
made  by  a  bit  of  an  exploded  percussion-cap.  Had 
the  fragment  rebounded  from  the  capsule  of  the  lens, 
or  had  it,  perchance,  penetrated  the  lens  itself  ?  These 
points  could  not  be  then  determined,  for  a  large  amount 
of  pus  occupied  the  anterior  chamber  and  concealed  the 
pupil.  The  iris  was  prolapsed  into  a  puncture,  which 
had  been  made  in  the  lower  border  of  the  cornea  for 
the  purpose  of  evacuating  the  pus.  '  It  was  in  this  con- 
dition that  I  first  saw  the  patient.  It  was  impossible, 
at  that  time,  to  decide  whether  the  purulent  masses 
which  still  occupied  the  pupil  were  nodules  of  exuda- 
tion upon  the  anterior  capsule,  or  were  swollen  and 
suppurating  fragments  of  the  wounded  lens ;  the  lat- 
ter condition,  however,  seemed  the  more  probable. 
Nevertheless,  the  pus  gradually  disappeared,  and  al- 
though the  pupillary  border  of  the  iris  was  found  ex- 
tensively adherent  to  the  anterior  capsule,  neither  the 
latter  nor  the  lens  had  been  wounded.  The  eye  con- 
tinued to  improve,  but,  along  with  some  lachrymation 
and  pain,  a  slight  subconjunctival  injection  persisted 
around  the  dark-colored  spot  where  the  iris  had  pro- 
lapsed. One  day,  while  examining  the  eye  more  care- 
fully, in  order  to  discover  the  cause  of  the  obstinate 
irritation,  I  noticed  that  the  dark  prolapsed  iris  had 
a  distinct  metallic  lustre,  so  that  1  at  once  suspected 


20  SYMPATHETIC   DISEASES    OF    THE   EYE. 

the  presence  of  a  piece  of  metal:  With  a  pair  of  fine 
forceps  I  extracted,  from  a  small  excavation  in  the 
corneal  edge  of  the  sclerotica,  where  it  lay  imbedded, 
a  rolled  up  piece  of  copper  cap,  4  mm.  long  and  2^ 
mm.  wide.  All  the  signs  of  irritation  now  disap- 
peared in  a  very  short  time.  A  fortunate  accident 
had  saved  both  the  wounded  eye  and  its  mate.  The 
piece  of  metal  had  penetrated  the  cornea,  struck  the 
anterior  capsule  of  the  lens  without  opening  it,  and 
had  then  rebounded  to  the  bottom  of  the  posterior 
chamber,  where  it  lay  directly  upon  the  ciliary  body 
and  excited  a  severe  inflammation  of  the  whole  ante- 
rior part  of  the  eyeball.  The  puncture  of  the  cornea, 
which  had  been  made  for  the  removal  of  the  pus  from 
the  anterior  chamber,  having  luckily  been  unskilfully 
performed,  a  portion  of  the  iris  fell  through  the  inci- 
sion, and  into  the  pocket-like  duplicature  thus  made 
the  piece  of  metal  was  received.  After  necrosis  of  the 
prolapsed  iris  the  metal  lay  freely  exposed  at  the  edge 
of  the  cornea.  Had  the  operation  been  made  accord- 
ing to  rule  the  iris  would  not  have  prolapsed,  and  the 
foreign  body  left  within  the  globe  would,  in  all  prob- 
ability, have  produced  a  dangerous  cyclitis,  with  the 
chance  of  involving  the  second  eye. 

The  good  results  attained  in  the  two  injuries  just 
described  were  due  to  surgical  interference  :  in  the 
one  case,  intentional,  and,  in  the  other,  accidental. 
But  sometimes  severe  wounds  of  the  eye  may  termi- 


ETIOLOGY.  21 

Date  favorably,  without  any  surgical  interference  what- 
ever. A  boy,  twelve  years  old,  was  shot  in  the  left 
eye  with  an  arrow  from  the  cross-bow  of  a  playmate. 
The  arrow  stuck  fast  in  the  eye  until  pulled  out  by  his 
companion.  The  eye  reddened,  but  was  not  painful 
at  first,  and,  immediately  after  the  accident,  the  boy 
said  that  his  sight  was  as  good  as  ever.  Four  days 
later,  on  awaking  from  sleep,  he  noticed  that  he  could 
see  very  little  with  the  wounded  eye,  and,  later  in  the 
same  day,  pain  supervened,  with  almost  complete  blind- 
ness of  the  eye.  On  the  next  day  the  eye  was  exam- 
ined by  a  surgeon,  who  found  a  small,  round  wound  in 
the  sclerotica,  behind  the  lower  and  inner  edge  of  the 
cornea.  There  was  also  pericorneal  injection ;  the  pu- 
pil was  contracted  ;  the  unwounded  lens  was  in  its 
proper  position  ;  but  the  vitreous  humor  was  clouded 
throughout.  The  tension*  of  the  eyeball  was  normal, 
and  no  spot  manifested  any  sensitiveness  to  the  touch ; 
but  the  vision  was  so  reduced  that  light  and  darkness 
could  barely  be  distinguished.  The  inflammatory 
symptoms  soon  became  more  marked,  and  pus,  which 
must  have  come  from  the  ciliary  body,  inasmuch  as 
both  cornea  and  iris  were  uninflamed,  appeared  in  the 


*  By  the  word  tension,  which  will  be  of  frequent  recurrence  in 
these  pages,  we  mean  the  feeling  of  hardness  or  softness  of  the 
eyeball,  when  we  press  upon  it  through  the  closed  lids  with  the  fin- 
gers. If  the  eye  feels  softer  than  the  normal  organ,  we  say  the 
tension  is  diminished  ;  if  harder,  the  tension  is  increased. — TR8. 


22  SYMPATHETIC   DISEASES    OK    THE    EYE. 

anterior  chamber.  Gradually,  however,  all  the  inflam- 
matory symptoms  subsided,  and  the  turbid  vitreous 
again  became  clear.  Two  years  later,  when  I^saw  the 
boy  for  the  last  time,  the  ophthalmoscope  revealed  a 
very  striking  condition  of  things  in  the  fund  us  of  the 
eye.  The  retina,  as  well  as  all  the  rest  of  the  interior 
of  the  eye,  was  visible,  although  somewhat  indistinct. 
A  large,  dark  cord  extended  from  the  optic  papilla,  di- 
rectly through  the  vitreous  body,  to  the  point  where 
the  arrow  had  entered  the  eye.  Immediately  before 
its  termination  at  this  point,  the  cord  divided  into  nu- 
merous slender  threads.  Its  direction  indicated  the 
exact  course  of  the  arrow-head,  which  had,  therefore, 
traversed  the  whole  vitreous  humor  and  become  fixed 
in  the  optic  papilla.  A  vascular  neoplasm,  which  pro- 
jected toward  the  vitreous,  from  near  the  insertion  of 
the  cord,  appeared  to  have  been  due  to  the  irritation 
in  the  papilla  by  the  foreign  body.  The  eye  was  free 
from  any  symptoms  of  irritation,  and  showed  two-sev- 
enths of  the  normal  amount  of  vision,  with  a  perfectly 
clear  visual  field. 

We  now  have  to  note  another  important  point.  A 
foreign  body  imprisoned  in  the  eye  may  prove  a  source 
of  constant  irritation  for  years,  exciting  from  time 
to  time  severe  inflammation  of  the  wounded  eye,  and 
justifying  the  fear  that  sympathetic  disease  may  at  any 
time  break  out  in  the  sound  eye.  If,  however,  during 
a  violent  attack  of  inflammation,  the  eyeball  should 


ETtOLOGY.  23 

unexpectedly  open  at  some  point,  and  the  foreign 
body,  so  long  present,  be  expelled  from  the  eye,  either 
spontaneously  or  by  surgical  assistance,  a  new  and 
happy  turn  may  be  given  to  the  case,  affording  perma- 
nent rest  to  the  injured  eye,  and  assuring  the  other 
from  threatened  destruction.  I  have,  however,  seen 
this  favorable  result  but  twice,  the  offending  body,  in 
each  instance,  being  a  fragment  of  glass. 

In  one  case,  a  piece  of  glass — so  large  as  to  ex- 
cite wonder  that  it  could  have  either  entered  or  occu- 
pied the  cavity  of  the  eyeball— came  to  light,  after  a 
violent  inflammatory  attack,  and  was  finally  extracted 
through  the  sclerotica,  after  the  spontaneous  opening 
had  been  greatly  enlarged. 

The  second  case  was  that  of  a  woman  who  applied 
for  an  artificial  eye.  A  splinter  of  glass  had  flown  into 
her  left  eye,  in  early  youth,  and  had  ever  since  been  a 
source  of  constant  irritation,  provoking  severe  inflam- 
matory attacks  in  the  affected  eye,  and  greatly  impair- 
ing the  vision  of  the  opposite  eye.  She  reported  that, 
during  a  violent  inflammatory  exacerbation,  the  splinter 
had  appeared  at  the  surface  and  been  spontaneously 
expelled.  After  that  event  the  injured  eye  gave  no 
further  trouble,  and  the  second  eye  could  be  used  for 
all  sorts  of  work. 

The  injuries  of  the  ciliary  ~body  and  its  vicinity, 
known  to  give  rise  to  sympathetic  disease,  are  appro- 
priately classified  as  accidental  and  operative  injuries. 


24  SYMPATHETIC   DISEASES   OF   THE   EYE. 

Thejirst  of  these  divisions  comprises :  penetration  of 
foreign  bodies  into  the  ciliary  body,  with  lodgement 
therein  ;  punctured  or  incised  wounds  of  the  ciliary 
body,  without  lodgement  of  a  foreign  body;  contused 
or  lacerated  wounds  of  the  ciliary  body,  inflicted  by 
blunt  agents ;  incised,  punctured,  and  lacerated  wounds 
of  the  periphery  of  the  cornea,  with  or  without  injury 
of  the  ciliary  body,  whereby  the  periphery  of  the  iris 
alone,  or  along  with  it  a  portion  of  the  ciliary  body, 
becomes  incarcerated  in  the  wound ;  and  finally,  con- 
tusions of  the  ciliary  body,  from  mechanical  violence 
applied  to  the  eyeball,  without  opening  it. 

A  foreign  object  lodged  in  the  ciliary  body  may  some- 
times become  eucapsuled,  and  so  be  made  innocuous. 
When  this  happens,  the  diagnosis  of  its  presence  is 
certainly  very  difficult.  Bowen,  however,  has  observed 
(1875)  that  such  an  object,  after  a  long  and  harmless 
stay,  may  suddenly  and  dangerously  announce  its 
presence.  A  particle  of  iron,  the  size  of  a  pin-head, 
lay  among  the  fibres  of  the  ciliary  muscle  for  nine 
years,  causing  extensive  thickening  in  its  neighbor- 
hood, as  was  found  at  a  subsequent  examination.  After 
this  long  period,  pain  in  the  ciliary  body  was  felt,  on 
pressing  the  spot  where  the  injury  had  been  inflictedj 
and,  a  few  weeks  later,  sympathetic  ophthalmia  super- 
vened, which  only  ceased  after  enucleation  of  the 
wounded  eye. 

It  thus  appears  certain  that  a  foreign  body,  either 


ETIOLOGY.  25 

free  or  encapsuled,  may  harmlessly  remain  for  a  long 
time,  and  even  for  life,  not  only  in  the  ciliary  body, 
but  in  any  other  part  of  the  eye.  It  is,  on  the  other 
hand,  no  less  clear,  from  another  case,  also  reported 
by  Bo  wen  (1875),  that  the  wounded  eye,  even  after  a 
very  protracted  interval  of  quiescence,  gains  no  certain 
immunity  from  severe  inflammation  and  ensuing 
sympathetic  disturbance,  liable,  as  they  both  are,  to  be 
caused  by  the  presence  of  the  original  foreign  body. 
In  the  latter  case,  a  piece  of  metal,  two  and  a  half 
millimetres  long,  lay  imbedded  in  the  optic  nerve  for 
seventeen  years,  and  it  was  only  after  it  had  produced 
inflammation  and  disorganization  of  the  uveal  tract, 
that  sympathetic  phenomena — intolerance  of  light,  cil- 
iary injection,  and  discoloration  of  the  iris— appeared 
in  the  uninjured  eye. 

Although  the  injuries  of  the  ciliary  body  are  much 
more  dangerous  than  analogous  injuries  of  other  parts 
of  the  eye,  from  the  greater  proneness  of  the  former 
to  develop  the  severe  train  of  symptoms  presently  to 
be  described,  yet  a  simple  injury  of  the  ciliary  body, 
when  not  complicated  by  prolapse  of  the  iris,  or  in- 
carceration of  some  portion  of  the  ciliary  body  in  a 
penetrating  wound,  is  not  often  followed  by  serious 
consequences. 

Violent  contusions  and  concussions,  inflicted  upon 
the  eye  by  blunt  bodies — for  example,  the  naked  fist, 

or   one   in  which   the  fingers  are  covered  with  heavy 

2 


26  SYMPATHETIC    DISEASES   OF   THE   EYE. 

rings — play  relatively  the  most  frequent  part  in  the 
etiology  of  cyclitis,  and  its  associate  diseases,  irido- 
cyclitis  and  irido-cyclo-choroiditis.  Next  in  order 
of  frequency  come  penetrating  and  cutting  wounds, 
without  prolapse  or  constriction  of  any  of  the  parts  ; 
and  least  frequently  of  all  (whatever  may  be  their  in- 
herent danger),  the  penetration  and  permanent  loca- 
tion of  small  foreign  bodies  within  the  ciliary  body. 

The  symptoms  and  anatomical  changes  set  on  foot 
l>y  injuries  of  the  ciliary  body  may  be  so  insidious  and 
painless,  at  the  start,  as  to  be  quite  unrecognizable. 
Soon,  however,  more  marked  symptoms  appear :  the 
injured  eye  becomes  intolerant  of  light  and  bathed  in 
tears,  while  a  ring  of  blood-vessels  environs  fhe  cornea. 
If  we  touch  the  ciliary  region  with  a  blunt  probe,  or 
simply  press  with  the  finger  through  the  .closed  lids, 
the  patient  complains  of  its  sensitiveness,  and,  in  par- 
ticular spots,  of  acute  pain.  The  cornea  becomes  hazy 
and  dull  on  its  external  surface,  and  the  iris,  if  visible 
through  the  cornea,  is  seen  to  be  discolored,  its  nat- 
ural lustre  gone,  and  its  striated  appearance  obscured. 
The  pupil  is  still  open,  but  atropia  no  longer  exerts 
any  influence  upon  its  size.  We  soon  discover  foun- 
dation for  our  suspicion  that  the  pupillary  edge  of  the 
iris  is  adherent  to  the  capsule  of  the  lens ;  while  the 
whole  posterior  chamber  is  filled  with  inflammatory 
exudation,  gluing  the  iris,  the  ciliary  body,  and  the  an- 
terior capsule  firmly  together.  Pus  may  occupy  the 


ETIOLOGY.  27 

floor  of  the  anterior  chamber,  having  forced  its  way  di- 
rectly thither  from  the  ciliary  body,  through  the  liga- 
mentum  pectinatum  iridis  and  its  cellular  plate.  If  the 
pupil  be  still  sufficiently  clear  to  permit  of  the  use  of 
the  ophthalmoscope,  we  can  with  difficulty  distinguish 
the  fund  us  of  the  eye  through  the  intervening  tur- 
bidness.  So  long  as  this  opacity  is  still-diffuse,  it  is 
hard  for  the  observer  to  decide  how  much  of  it  de- 
pends on  the  cornea,  as  well  as  on  the  turbid  aqueous 
full  of  pus-corpuscles,  or  how  much  on  the  vitreous. 
But  when  dark  objects,  of  varying  size  and  shape, 
float  about  in  the  affected  eye  upon  its  being  quickly 
moved  to  and  fro,  we  know  that  the  vitreous  humor  is 
involved  in  the  pathological  process.  Vision,  mean- 
while, has  diminished  exceedingly. 

The  eyeball  now  becomes  ominously  soft  to  the 
touch,  and  the  acuteness  of  vision  markedly  diminished. 
The  anterior  chamber  is  narrowed,  inasmuch  as  the 
lens  is  pushed  forward  toward  the  already  turbid  and 
flattened  cornea.  The  periphery  of  the  chamber  may, 
however,  appear  deeper  at  places  than  normal,  inas- 
much as  the  masses  of  exudation  which  occupy  the 
posterior  chamber  have  formed  a  cicatricial  tissue  be- 
tween the  iris  and  anterior  capsule,  become  consoli- 
dated, and  so  dragged  the  ciliary  border  of  the  iris 
backward  toward  the  lens.  The  iris  itself,  having 
passed  through  its  stage  of  proliferation  and  soften- 
ing, is  now  atrophied,  and  turned  to  a  dirty » yellow 


28  SYMPATHETIC   DISEASES   OF    THE    EYE. 

color.  The  black  pigment  which  lines  its  posterior 
surface  is  visible  through  the  anterior  layer,  giving  it  a 
dotted  appearance,  while  here  and  there  tortuous  veins 
are  displayed,  owing  to  the  inflammatory  swelling 
of  the  ciliary  body,  whereby  the  venous  blood  of  the 
iris  is  now  impeded  in  its  passage  to  the  choroid.  The 
pupil  may,  at  this  stage,  be  still  permeable  for  light, 
but  more  frequently  it  is  blocked  with  masses  of  ex- 
udation. 

The  morbid  process  culminates  when  the  inflam- 
mation of  the  ciliary  body  (cyclitis)  is  communicated 
backward  to  the  choroid  (choroid itis),  which,  in  turn, 
involves  the  contiguous  retina  (retinitis),  whilst  the 
nutrition  of  the  deeper  structures  of  the  eye  becomes 
BO  disturbed  that  a  marked  reduction  in  the  mass  of 
the  vitreous  humor  takes  place.  The  direct  conse- 
quence of  the  atrophy  of  the  vitreous  is  the  loss  of 
the  normal  tension  of  the  globe,  which  now  feels  soft, 
and  may  become  so  flaccid  as  to  be  indented  at  the 
places  corresponding  to  the  recti  muscles.  But  even 
after  phthisis  of  the  entire  eyeball,  with  total  inflam- 
matory destruction,  or  even  detachment,  of  the  retina, 
and.  consequent  extinction  of  vision,  the  eye  does  not 
subside  into  quiescence.  The  offending  ciliary  region 
may  still  be  tender  and  irritable  to  the  touch,  painful 
upon  the  slightest  occasion,  and  a  source  of  constantly 
impending  danger  to  the  other  eye. 

We  have,  moreover,  to  mention  Mooren's  assertion 


ETIOLOGY.  29 

that  after  the  introductory  symptoms,  such  as  peri- 
corneal  injection,  photophobia,  lachrymation,  and  par- 
tial sensitiveness  of  the  ciliary  body,  in  a  typical  case 
of  simple  acute  cyclitis,  we  first  see  an  increase  of 
depth  in  the  anterior  chamber,  due  to  the  inflamma- 
tory adhesion  of  the  periphery  of  the  iris  to  the  ciliary 
body.  We  are  also  struck  by  the  fact  that  no  iritic 
adhesions  to  the  anterior  capsule,  even  at  the  ^>upil- 
lary  border,  exist  at  this  time,  the  pupil  being  readily 
dilatable  by  the  instillation  of  atropia.  Should  the 
retraction  of  the  periphery  of  the  iris  progress,  then 
the  veins  of  the  iris  dilate,  the  aqueous  humor  becomes 
cloudy,  pus  appears  in  the  anterior  chamber,  and  opa- 
cities quickly  and  copiously  form  in  the  vitreous  humor. 
When,  in  connection  with  an  injury  of  the  ciliary 
body,  the  eyeball  is  opened  by  a  punctured  or  incised 
wound,  or  is  lacerated  and  contused  by  some  blunt 
instrument  (cow's  horn),  or  a  projectile,  the  injury  is 
usually  complicated  by  a  prolapse,  into  the  wound,  of 
a  portion  of  the  ciliary  body,  or  the  periphery  of  the 
iris,  or  both  together.  In  the  majority  of  such  cases, 
the  cyclitis,  or  irido-cyclitis,  is  directly  produced  by 
the  injury,  and  not  by  the  incarceration  of  the  ciliary 
body  or  iris.  Wounds  of  this  kind  are  sometimes  very 
remarkable.  I  once  saw  an  eye  that  had  been  bitten 
by  a  horse,  so  that  the  organ  was  lost,  after  violent 
symptoms  of  cyclitis,  and  the  other  eye  subsequently 
suffered  from  severe  sympathetic  ophthalmia.  Lebrun 


30  SYMPATHETIC   DISEASES   OF   THE   EYE. 

(1870)  reported  a  case  in  which  a  leech,  applied  to  the 
neighborhood  of  an  eye  for  therapeutical  purposes, 
strayed  to  the  edge  of  the  cornea,  where  it  inflicted  a 
bite  that  was  followed  by  sympathetic  symptoms  in 
the  other  eye.  We  have  already  mentioned  (page  20) 
an  extraordinary  case  in  which  a  foreign  body  flew 
through  the  cornea,  as  far  backward  as  the  anterior 
capsule,  from  which  it  fell  to  the  floor  of  the  posterior 
chamber,  and  there  rested  in  menacing  contact  with 
the  ciliary  body. 

Both  contusions  and  perforations  of  the  eyeball  may 
cause  cyclitis  in  an  indirect  way.  Thus,  a  contusion 
may  partially  lacerate  the  suspensory  ligament  (zonula 
Zinnii),  so  that  the  lens  may  either  sink  downward 
upon  the  ciliary  body,  and  excite  irritation  by  its  con- 
tact with  the  latter,  or  it  may  drag  upon  the  ciliary 
body  through  its  remaining  attachments  to  the  zonula, 
and  produce  a  similar  effect.  Again,  when  a  foreign 
body  has  penetrated  the  lens,  or  extensively  lacerated 
its  capsule,  the  fragments  of  the  mutilated  lens  may 
fall  into  the  bottom  of  the  posterior  chamber,  and 
cause  severe  inflammation  of  the  iris  and  ciliary  body. 
If,  however,  the  fragments  of  the  lens  fall  into  the 
anterior  chamber,  their  presence  usually  provokes 
much  less  inflammation.  Thus  may  injuries  of  the  eye 
lead  indirectly,  through  lesions  of  the  lenticular  appa- 
ratus, to  disease  of  the  uveal  tract,  and,  later,  to  sym- 
pathetic affections  of  the  opposite  eye. 


ETIOLOGY.  31 

We  must  here  remind  ourselves  that  it  is  not  only  the 
accidental  injuries  of  the  eye,  but  also  those  which  are 
incidental  to  surgical  operations,  that  may  initiate 
sympathetic  ophthalmia.  Among  the  operative  inju- 
ries, the  one  called  iridodesis,  and  the  various  opera- 
tions for  cataract,  occupy  the  first  rank.  Critchett 
(1858)  devised  the  operation  of  iridodesis,  with  a  view 
to  provide  the  disabled  eye,  under  certain  circumstan- 
ces, with  better  vision  than  could  be  gained  by  iridec- 
tomy. 

The  operation  called  iridectomy  consists  in  making 
a  new  opening  in  the  iris  for  the  rays  of  light  to  enter 
the  eye,  when  the  natural  pupil  is  covered  by  a  central 
opacity  of  the  cornea,  or  when  the  pupil  lies  in  front 
of  a  stationary  central  cataract.  A  piece  of  the  iris  is 
excised,  so  that  a  portion  of  the  still  transparent  cornea, 
or  lens,  faces  the  artificial  opening.  This  operation, 
when  performed  for  optical  purposes  only,  has  not 
usually  given  satisfactory  results.  It  is,  indeed,  in- 
valuable when  the  central  opacity  of  the  cornea  wholly 
conceals  the  pupil,  and  is  at  the  same  time  completely 
or  nearly  opaque,  provided  that  the  outer  portion  of 
the  cornea,  which  appears  normal,  is  really  so,  as  re- 
gards both  transparency  and  curvature.  Moreover,  in 
the  rare  disease  called  stationary  nuclear  cataract,  in 
which  the  central  portion  of  the  lens  lying  directly 
behind  the  pupil  is  totally  opaque,  and  a  considerable 
margin  of  the  lens  beyond  the  opacity  is  perfectly 


32  SYMPATHETIC   DISEASES    OF   THE   EYE. 

transparent,  iridectomy  is  a  reliable  resource.  But 
such  clear  indications  for  the  operation  are  seldom 
met  with,  for  the  offending  spot  in  the  centre  of  the 
cornea  oftentimes  falls  far  short  of  complete  opacity, 
whilst  the  central  cataract,  on  account  of  which  the 
patient  demands  "  more  light,"  is  almost  always  of  the 
so-called  lamellar  variety,  in  which  an  opaque  lamella 
or  zone  intervenes  between  the  nucleus  and  cortical 
portion,  which  are  both  clear.  In  many  cases  the 
impairment  of  vision  is  so  slight  as  not  at  all  to  inter- 
fere with  ordinary  pursuits,  and  no  surgical  operation 
is  warrantable  under  such  circumstances.  Further- 
more, the  lamellar  variety  of  cataract,  even  in  its  ex- 
treme degree  of  development,  still  permits  a  certain 
amount  of  light  to  enter  the  interior  of  the  eye.  If, 
therefore,  an  iridectomy  is  performed  on  an  eye  affect- 
ed with  an  incomplete  opacity  of  the  cornea  or  lens, 
the  retina  receives  light  not  only  through  the  newly 
made  aperture,  but  through  the  old  pupil.  The  fail- 
ure of  the  opacity  to  prevent  the  transmission  of  light 
through  the  original  pupil  is  a  source  of  disturbance 
to  the  eye  as  an  optical  apparatus,  because  in  the  eye, 
as"  in  the  camera  obscura,  clearly  defined  images  are 
only  produced  when  all  irregularly  refracted  rays  are 
excluded.  When  diffused  light  is  thrown  over  the 
retinal  image,  the  latter  becomes  indistinct.  For  the 
foregoing  reasons,  the  performance  of  iridectomy, 
under  the  circumstances  above  mentioned,  does  not 


ETIOLOGY.  33 

enable  the  eye  to  see  well ;  for  not  only  does  diffused 
light  continue  to  reach  the  retina,  but  the  dazzling 
sensation  caused  by  too  brilliant  illumination  of  the 
field  of  vision  is  aggravated  by  the  operation,  inas- 
much as  the  pupil  is  thereby  not  only  deprived  of  its 
contractile  power,  but  its  area  is  greatly  enlarged. 

On  account  of  the  excessive  size  of  the  pupil,  its  loss 
of  reactionary  power,  and  the  disturbance  of  the  re- 
tinal image  by  diffused  light,  which  follow  iridectomy, 
an  attempt  was  made  to  obviate  these  evils  by  substi- 
tuting the  operation  called  iridodesis,  in  performing 
which  a  small  incision  is  made  in  the  cornea,  close  to 
the  sclerotica,  and  the  peripheral  portion  of  the  iris 
seized  and  drawn  out  of  the  wound,  with  such  precau- 
tions that  the  entire  pupillary  border  is  left  within  the 
anterior  chamber.  A  loop  of  thread  is  afterward  tied 
around  the  prolapsed  iris,  to  prevent  it  from  slipping 
back  into  the  eye  ;  the  strangulated  piece  then  rapidly 
necroses,  falls  off  with  the  thread,  and  the  wound  is 
soon  healed.  The  pupil  has  thus  been  transformed 
into  an  oval  or  longitudinal  opening,  and  moved  in 
toto  toward  the  place  of  incision,  the  portion  of  the 
iris  directly  opposite  the  place  of  incision  having  been 
stretched  to  permit  of  the  dislocation.  The  displaced 
pupil,  with  its  constrictor  pupillae  intact  and  its  reac- 
tionary function  unimpaired,  covers  a  scarcely  greater 
area  than  it  did  before  the  operation.  Moreover,  a 

portion  of  the  iris  is  interposed,  as  a  diaphragm,  be- 

2 


£*  SYMPATHETIC   DISEASES    OF    THE   EYE. 

hind  the  semi-opaque  corneal  spot,  or  in  front  of  the 
partly  translucent  cataract,  thereby  protecting  the  re- 
tina from  diffused  rays  of  light ;  so  that,  barring  the 
sacrifice  of  some  trueness  of  the  corneal  curvature  (an 
evil  which  Pagenstecher  sought  to  aroid  by  removing 
the  incision  into  the  verge  of  the  sclerotica),  we  now 
have  an  eye  which,  although  not  projecting  an  abso- 
lutely perfect  image  upon  the  retina,  certainly  pos- 
sesses better  vision  than  it  would  have,  had  an  iridec- 
tomy  been  performed. 

Wecker  practises  iridodesis  in  those  cases  in  which 
the  lens,  from  whatever  cause,  has  become  dislocated, 
so  that  its  centre  no  longer  corresponds  to  the  centre 
of  the  pupil,  or,  more  strictly  speaking,  to  the  axis  of 
vision.  If,  for  example,  the  zonula  has  been  torn  at 
its  lower  and  inner  insertion,  the  lens  is  displaced  up- 
ward and  outward,  so  that  the  space  thus  left  between 
the  lower  internal  border  of  the  lens  and  the  adjacent 
ciliary  processes  is  partly  visible  through  the  pupil 
when  dilated  with  atropia,  or  even  when  of  normal 
size.  Two  images  of  an  object,  seen  with  such  an  eye, 
are  thus  projected  upon  the  retina:  one  of  them  by 
the  cornea,  aqueous  humor,  lens,  and  vitreous  humor ; 
and  the  other,  by  a  refractive  system  from  which  the 
lens  is  absent.  If  the  image  made  without  the  aid  of 
the  lens  be,  for  any  reason,  the  more  useful  of  the  two, 
the  operation  of  iridodesis  enables  us  to  transfer  the 
pupil  permanently  to  a  part  of  the  cornea  behind 


ETIOLOGY.  35 

which,  the  lens  is  absent,  whilst,  by  the  same  proce- 
dure, .the  iris  on  the  opposite  side  -is  stretched  over  the 
dislocated  lens,  so  as  to  cut  off  the  second  image,  which 
would  otherwise  interfere  with  distinct  vision. 

Iridodesis  was  at  first  regarded  as  a  perfectly  safe 
operation.  But,  in  1863,  Alfred  Graefe  published  the 
following  significant  case,  in  which  iridodesis  was  per- 
formed on  the  eyes  of  a  workman,  aged  twenty-three. 
Both  eyes  of  the  patient  were  affected  with  lamellar 
cataract,  which,  however,  still  permitted  him  to  read 
No.  3  of  Jaeger's  test-types.  Vision  was  improved  im- 
mediately after  the  operation  ;  but  eight  weeks  later 
Graefe  found  the  man  Mind  in  both  eyes,  with  occlu- 
sion of  the  pupils,  in  consequence  of  irido-cyclitis. 
The  eyes,  however,  were  not  soft.  The  patient  could 
see  well  with  both  eyes  during  the  first  week,  at  the 
end  of  which  time,  without  any  apparent  cause,  the 
sight  diminished,  first  in  one  eye,  and  very  soon  there- 
after in  the  other,  until  it  was  reduced,  at  the  time  of 
the  examination,  to  a  merely  quantitative  perception  of 
light.  The  exciting  cause  of  the  irido-cyclitis,  in  each 
eye,  was  attributed  by  Graefe  to  the  stretching  of  the 
iris,  incident  to  the  iridodesis.  Did  not,  however,  sym- 
pathetic inflammation  play  its  role  in  this  case  ?  It  is 
possible  that  the  operation  had  directly  excited  irido- 
cyclitis  in  one  eye  only,  and  the  inflammation  had  ex- 
tended sympathetically  to  the  other,  so  that  the  same 
lesions  would  have  appeared  in  the  second  eye  even  if  ic 


36  SYMPATHETIC   DISEASES   OF   THE    EYE. 

had  not  undergone  the  operation.  Although  the  nearly 
simultaneous  involvement  of  the  two  eyes,  in  G'raefe's 
case,  makes  the  latter  opinion  less  trustworthy,  never- 
theless, as  we  know  from  experience  that  irido-cyclitis 
is  prone  to  be  followed  by  sympathetic  disease,  and  as 
Graefe  established  the  existence  of  irido-cyclitis  de- 
pending on  the  iridodesis,  it  must  be  admitted  that  this 
operation  is  not  devoid  of  both  primary  and  sympa- 
thetic danger.  In  fact,  soon  after  Graefe's  case  came 
to  light,  one  was  reported  by  Steffan  (1864),  in  which 
a  girl  aged  nineteen,  who  had  undergone  iridodesis  in 
one  eye  only,  was  affected,  five  weeks  after  the  opera- 
tion, with  irido-cyclitis  in  both  eyes.  The  disease  may 
have  first  appeared  in  the  wounded  eye  so  insidiously 
as  to  receive  no  attention  ;  but  it  was  not  until  the 
affection  had,  some  weeks  later,  extended  to  the  hith- 
erto perfectly  sound  eye,  that  the  patient  applied  for 
relief. 

When,  during  a  visit  to  London  in  1864,  I  men- 
tioned to  Critchett  that  the  unfortunate  cases  of 
Graefe  and  Steffan  had  produced  a  want  of  confidence 
in  iridodesis,  among  German  oculists,  he  was  not  a  lit- 
tle surprised  at  the  two  failures,  as  he  had  never  en- 
countered like  results  in  his  very  large  personal  expe- 
rience with  the  operation.  My  own  operations  have, 
likewise,  been  successful.  But,  on  the  other  hand, 
unsuccessful  cases  and  unfavorable  criticisms  of  irido- 
desis have  been  sufficiently  frequent  in  ophthalroolo- 


ETIOLOGY.  37 

gical  literature,  since  1864,  to  place  the  operation  where 
it  now  remains — in  discredit. 

Of  far  greater  importance  than  iridodesis,  as  regards 
the  danger  of  exciting  inflammation,  which  may  be 
propagated  sympathetically  to  the  second  eye,  are  the 
operations  for  the  relief  of  cataract. 

One  of  the  fundamental  methods  of  operating  for 
this  disease,  that  of  depression  or  reclination,  by  which 
a  hard  cataract  is  forcibly  thrust  away  from  the  axis 
of  the  visual  rays  into  the  vitreous  body,  is  now  almost 
totally  abandoned  on  account  of  the  destructive  con- 
sequences that  ensue,  not  only  in  the  operated  eye, 
but,  secondarily,  in  its  fellow.  The  displaced  lens 
often  plays  the  part  of  a  foreign  body — resting,  it  may 
be,  in  disagreeable  contact  with  the  ciliary  body  and 
choroid.  It  may  thus  lead  to  inflammation  of  the 
uveal  tract,  if,  indeed,  this  condition  has  not  already 
Jbeen  set  up  by  the  operation  itself.  The  bad  repute 
into  which  reclination  has  fallen  is,  however,  due  rather 
to  the  danger  incurred  by  the  eye  undergoing  opera- 
tion than  to  an  appreciation  of  the  sympathetic  dis- 
turbances that  may  subsequently  develop. 

Nor  are  the  two  operations  of  division  and  extrac- 
tion, so  extensively  employed  in  our  days,  wholly  de~ 
void  of  analogous  risks.  The  object  of  division  or 
disci ssion  of  a  cataract  is  to  lacerate  the  anterior  cap- 
sule and  break  up  the  substance  of  the  lens,  so  that  the 
latter  shall  come  into  contact  with  the  aqueous  humor. 


f3S  SYMPATHETIC   DISEASES    OF   THE   EYE. 

If  the  lens  be  only  partially  opaque,  as  in  lamellar 
cataract,  it  becomes  wholly  so  soon  after  exposure  to 
the  aqueous,  and  its  fragments  are  gradually  dissolved 
and  absorbed  until  the  cataract  disappears.  It  some- 
times happens,  either  when  proper  precautions  have 
not  been  taken  during  the  operation,  or  in  spite  of 
them,  that  the  lenticular  fragments  imbibe  a  great  deal 
of  aqueous  humor,  swell  considerably,  press  upon  the 
iris,  and  cause  severe  iritis,  followed  rapidly  by  cycli- 
tis  and  possibly  by  sympathetic  disturbances.  Al- 
though division  is  regarded  by  oculists  as  a  very  im- 
perfect surgical  procedure,  there  are,  nevertheless,  a 
few  forms  of  cataract  to  which  no  other  is  so  well 
adapted.  Among  these  are  the  lamellar  cataract  and 
the  extremely  rare  variety  called  stationary  nuclear 
cataract,  in  both  of  which  the  transparent  periphery 
of  the  lens  adheres  so  intimately  to  the  capsule  that  it 
cannot  be  removed  by  the  extraction  method,  with  sat- 
isfactory results. 

Extraction  by  the  flap  operation^  and  v.  Graefe's 
method  of  modified  linear  extraction ,  are  the  two 
most  important  of  the  different  surgical  operations 
for  the  removal  of  cataract.  In  operating  by  the  first- 
named  method,  a  semicircular  flap,  involving  the  whole 
upper  half  of  the  cornea,  is  made  by  incising  the  lat- 
ter close  to  its  scleral  border.  A  large,  patulous  wound 
is  thus  produced,  through  which  the  lens  is  evacuated 
by  gentle  compression  of  the  globe.  In  v.  Graefe's 


ETIOLOGY.  39 

method  of  modified  linear  extraction  the  peculiarity 
of  the  incision  is  that  it  lies  entirely  in  the  sclerotica, 
and  does  not  form  a  flap,  its  only  curve  heing  that  of 
the  eyeball  itself.  The  incision  is  from  ten  to  twelve 
millimetres  long — its  middle  point  lying  at  the  topmost 
point  of  the  corneal  margin.  Through  this  incision 
the  lens  is  removed,  after  a  preliminary  iridectorny 
and  laceration  of  the  anterior  capsule.  The  operations 
now  most  in  vogue  are  a  sort  of  compromise  between 
the  old  flap  operation,  and  the  genuine  peripheral  lin- 
ear extraction  as  modified  by  v.  Graefe. 

When  the  old  method  of  removing  the  opaque  lens 
by  the  flap  operation  was  generally  practised,  very 
little  was  said  of  sympathetic  ophthalmia  after  op- 
erations for  cataract.  Now  and  then  we  heard  of 
irido-cy«litis  and  sympathetic  affections,  after  the  op- 
eration, and,  in  fact,  a  few  such  cases  are  matters  of 
record ;  but  we  undoubtedly  hear  much  more  of  sym- 
pathetic disturbances  in  connection  with  operations 
for  cataract,  since  the  era  of  linear  extraction. 

In  all  probability  the  first  enucleation  of  an  eyeball, 
upon  which  the  method  of  linear  extraction  had  been 
practised,  was  one  that  I  performed  in  1867,  on  ac- 
count of  sympathetic  ophthalmia  of  the  other  eye.  A 
cataractous  lens  had  been  removed  with  complete  suc- 
cess, by  the  flap  operation,  in  1865,  from  the  left  eye 
of  a  man  fifty  years  old.  One  year  later  Jaeger  op- 
erated on  the  right  eye  by  a  linear  method  (the  curved- 


40  SYMPATHETIC   DISEASES    OF    THE   EYE. 

lance  section).  Although  the  operation  was  skilfully 
performed,  without  any  prolapse  of  the  vitreous  hu- 
mor, irido-cyclitis  set  in,  and  was  followed  by  atrophy 
of  the  eyeball.  Thirteen  months  after  the  second  op- 
eration the  patient  again  applied  for  relief,  the  atro- 
phic  eye  having  never  become  quiescent,  and  being 
still  affected  with  pain  and  photopsies.  Six  weeks 
prior  to  his  reappearance  pain  commenced  in  the  left 
temple,  and,  later,  invaded  the  whole  side  of  the  head, 
undergoing  exacerbations  and  remissions,  but  never 
complete  suspension.  Along  with  these  symptoms, 
the  vision  of  the  left  eye  (which,  as  the  patient  declared, 
had  been  better,  with  the  aid  of  cataract-glasses,  since 
the  first  operation,  than  ever  before)  became  impaired, 
and,  at  the  date  of  examination,  was  reduced  to  one- 
fourteenth  of  normal,  whilst  the  whole  field  <ff  vision 
was  obscured  by  a  thick  mist.  The  tension  of  the  left 
eye  was  natural ;  both  cornea  and  iris  were  of  healthy 
appearance;  but  the  vitreous  humor,  when  illuminated 
by  the  ophthalmoscope,  was  seen  to  be  turbid  through- 
out. After  enucleation  of  the  right  eyeball,  the 
sympathetic  symptoms  and  the  ophthalmoscopic  ap- 
pearances gradually  improved  ;  but  no  amendment  of 
vision  had  taken  place  at  the  time  of  the  patient's  dis- 
charge, nine  weeks  after  the  operation.  In  the  enu- 
cleated eye  the  anterior  portion  of  the  choroid,  with 
the  neighboring  part  of  "the  ciliary  muscle,  could  be 
easily  detached  from  the  sclerotica,  whilst  the  connec- 


ETIOLOGY.  41 

tion  between  the  retina  and  the  vitreous  body  was 
likewise  abnormal.  In  this  unfortunate  case  the  ex- 
traction of  a  cataract  from  the  second  eye  had  not  only 
failed  of  its  immediate  object,  but  had  seriously  en- 
dangered the  restored  sight  of  the  first  eye. 

Knapp  reported  a  similar  unfortunate  case  in  1869. 
He  operated  successfully,  after  v.  Graefe's  method,  on 
the  left  eye  of  a  man  sixty  years  of  age.  The  eye 
healed  in  a  favorable  manner,  and,  six  days  after  the 
first  extraction,  the  operation  was  repeated  upon  the 
other  eye.  The  repetition,  however,  was  less  fortu- 
nate. There  was  haemorrhage  into  the  anterior  cham- 
ber, with  subsequent  iritis,  and,  later,  sympathetic  iritis 
of  the  first  eye.  Six  weeks  after  the.  operation,  both 
pupils  had  become  occluded,  and  both  eyeballs  some- 
what soft. 

When  the  subject  of  sympathetic  ophthalmia,  occur- 
ring after  cataract  operations,  was  introduced  by  Klein, 
at  the  Heidelberg  Ophthalmological  Congress  in  1874, 
a  whole  series  of  cases,  wherein  sympathetic  affections 
had  proceeded  from  the  linear,  or  the  various  modifi- 
cations of  the  linear,  extraction,  were  communicated 
by  oculists  present.  Becker  collected  (1875)  twenty- 
two  cases  (neglecting,  however,  to  include  Knapp's 
case)  of  sympathetic  disease,  resulting  after  cataract 
operations.  Seven  of  these  cases  followed  the  flap  op- 
eration, four  of  the  latter  being  well-recognized  speci- 
mens of  simple  senile  cataract ;  and  fifteen  occurred 


42  SYMPATHETIC   DISEASES    OF   THE   EYE. 

after  operations  by  the  linear  method.  Since  that 
time  further  reports  have  been  made  of  cases  of  sym- 
pathetic disease  resulting  from  v.  Graefe's  extraction 
method. 

The  various  causes  of  the  original  irritation  in  an  eye 
that  has  been  subjected  to  an  operation  for  cataract 
are:  incarceration  of  the  iris  in  the  wound,  with  or 
without  visible  prolapse  of  the  iris  (Klein,  v.  Arlt) ; 
imprisonment  in  the  wound  of  a  portion  of  the  capsule 
of  the  lens,  so  that  the  suspensory  ligament  and  ciliary 
body,  at  the  opposite  side  of  the  eye,  are  dragged  upon, 
or  detachment  of  the  ciliary  body  at  the  same  spot 
(Horner) ;  shrivelling  of  the  capsule  of  the  lens  (caused 
by  inflammatory,  exudation,  or  the  development  of  a 
secondary  cataract),  with  subsequent  stretching  of  the 
iris  and  ciliary  body  (Hanel,  Becker) ;  and  lastly,  di- 
rect injury  of  the  ciliary  body,  when  the  incision  has 
been  made  too  far  out  in  the  sclerotica  (Ed.  Meyer). 

Shall  we  include  simple  iridectomy  among  the 
surgical  operations  that  may  cause  sympathetic  oph- 
thalmia? Individual  cases,  showing  this  origin,  are  on 
record. 

"We  have,  so  far,  seen  how  traumatic  affections  of  the 
uveal  tract  may  endanger  the  integrity  of  the  unin- 
jured eye,  and  it  is  now  time  for  us  to  inquire  what 
importance  those  affections  of  the  same  regions,  which 
are  not  due  to  injuries,  may  have  in  the  production  of 
sympathetic  phenomena.  The  affections  not  due  to 


ETIOLOGY.  43 

inj  ury  are  divisible  into  two  classes :  the  one  embracing 
diseases  excited  by  mechanical  irritation  of  some  por- 
tion of  the  uveal  tract  by  bodies  which  cannot,  strictly 
speaking,  be  designated  as  traumatic  agents ;  and  the 
other,  comprising  the  purely  idiopathic  affections. 

In  the  first  class  belong  those  lesions  which  are  pro- 
duced by  spontaneous  dislocations  of  the  lens,  as  well 
as  by  cysts  of  the  iris,  choroidal  sarcomata,  retinal  gli- 
omata,  and  intra-ocular  cysticerci.  Mooren  believes 
that  irido-choroiditis  is  produced  by  a  spontaneously 
dislocated  lens,  only  when  the  latter  has  fallen  into 
the  anterior  chamber.  Hulke,  Knapp,  and  Nagel  saw 
cases  in  which  cysts  of  the  iris  had  caused  irido-choroi- 
ditis, with  sympathetic  irritation  ;  and  moreover,  impli- 
cation of  the  second  eye,  even  where  the  first  eye  never 
became  inflamed.  An  eye  affected  with  choroidal  sar- 
coma is  prone  to  be  succeeded  by  sympathetic  disease 
(Pagenstecher,  Norris,  Steffan,  Nettleship,  Salvioli, 
Hirschberg,  Knies) ;  but  it  should  be  borne  in  mind 
that  choroidal  sarcoma  is  very  frequently  due  to  a 
traumatic  agency.  Steinheim  reports  a  case  of  sym- 
pathetic irido-choroiditis  ensuing  upon  traumatic  gli- 
oma  of  the  retina.  The  cysticerci  are  analogous  to  the 
neoplasms,  in  their  causal  relations  to  primary  irido- 
choroiditis  and  its  sympathetic  sequelae. 

Idiopathic  cyclitis,  or  irido-cyclitis,  is  a  rare  disease. 
When  its  attacks  upon  the  two  eyes  are  not  synchro- 
nous, but  are  separated  by  a  certain  interval,  it  is  not 


44  SYMPATHETIC   DISEASES   OF   THE   EYE. 

always  easy  to  determine  whether  the  second  eye  is 
sympathetically  affected,  or  the  disease  in  both  eyes 
is  due  to  a  common  cause.  The  same  may  be  said  of 
irido-choroiditis  occasioned  by  the  syphilitic  poison, 
inasmuch  as  the  disease  of  the  second  eye  may  be 
a  sympathetic,  and  not  a  syphilitic  lesion.  When 
attacks  of  that  variety  of  irido-choroiditis,  which 
sometimes  attends  cerebro-spinal  meningitis,  occur 
simultaneously  in  both  eyes,  the  operation  of  a  com- 
mon cause  is  evident ;  but  if,  on  the  other  hand, 
one  eye  is  first  destroyed,  and,  later  in  the  disease  of 
the  nervous  system,  the  other  is  attacked  in  a  similar 
way,  it  is  probable  that  sympathetic  influences  have 
been  at  work.  Noyes  has  reported  a  curious  case  of 
herpes  zoster  ophihalmicus  of  the  left  eye  (that  variety 
of  herpes  zoster  in  which  the  eruption  follows  the  dis- 
tribution of  the  chief  cutaneous  branches  of  the  trige- 
minal  nerve),  in  consequence  of  which  both  eyes  were 
destroyed  by.subsequent  irido-choroiditis,  beginning  in 
the  right  eye  ten  months  later  than  in  the  left,  and 
without  herpetic  disease  of  the  former.  Jeffries,  like- 
wise, saw  a  case  of  temporary  sympathetic  disturbance 
transplanted  from  an  eye  that  had  been  destroyed  by 
the  same  variety  of  herpes  zoster. 

If  prolapse,  or  incarceration  of  the  iris  or  ciliary 
body,  within  a  traumatic  opening  of  the  eyeball,  near 
the  corneal  margin,  may  provoke  irritation  of  the 
nveal  tract  and  sympathetic  phenomena,  it  is  easy  to 


ETIOLOGY.  4:5 

understand  how  the  same  effect  may  be  produced 
when  one  or  other  of  these  structures  is  prolapsed  or 
incarcerated  within  a  similarly  situated  opening,  made 
in  the  eye  by  an  ulcer ative  process.  In  the  latter  con- 
dition very  much  the  same  relation  of  parts  exists  as 
after  iridodesis ;  and  indeed,  this  sort  of  natural  dis- 
placement of  the  pupil  is  quite  frequent.  *  But  we 
must  guard  ourselves  against  an  exaggerated  concep- 
tion of  the  danger  involved  in  the  accident.  I  cannot 
recollect  a  case,  in  my  personal  experience,  in  which  I 
have  seen  serious  results  to  the  second  eye  ensue  upon 
this  kind  of  cicatrization  of  the  iris,  even  of  its  periph- 
eral portion,  in  the  cornea. 

Where  the  ciliary  body  is  thus  imprisoned,  a  much 
more  encouraging  prognosis  can  be  made  than  after  a 
traumatic  injury,  inasmuch  as  the  latter  very  fre- 
quently superadds  a  direct  wound  of  the  ciliary  body. 
The  danger  of  sympathetic  inflammation  is  further  di- 
minished when  the  ulcerated  perforation  of  the  cornea 
is  very  large,  so  that,  instead  of  a  small  strangulation, 
a  great  part  of  the  iris  protrudes  through  the  cornea, 
becomes  indurated  and  thickened  from  exposure,  and 
forms  a  permanent  protuberance  (staphyloma)  through- 
out the  area  of  the  absent  cornea.  In  the  same  way, 
severe  chronic  inflammatory  processes  in  the  eye  may 
cause  the  sclerotic  zone,  just  outside  the  margin  of  the 
cornea,  to  become  relaxed  and  softened,  so  that  the  in  • 
tra-ocular  pressure  pushes  it  forward  in  such  a  manner 


46  SYMPATHETIC   DISEASES   OF    THE   EYE. 

as  to  present  a  series  of  small  staphylomata,  surround- 
ing a  greater  or  less  arc  of  the  corneal  periphery,  and 
in  some  cases  even  its  whole  circumference.  If,  under 
such  circumstances,  sympathetic  symptoms  should  de- 
clare themselves,  they  must  be  attributed,  not  so  much 
to  direct  stretching  and  laceration  of  the  ciliary  body, 
as  to  a  defect  in  the  suspensory  ligament,  somewhere 
around  the  equator  of  the  lens,  permitting  the  disloca- 
tion of  the  latter,  and  the  consequent  development  of 
sympathetic  phenomena  in  the  manner  before  de- 
scribed (page  30). 

So  far  as  we  have  at  present  proceeded,  it  has  ap- 
peared that  the  inflammatory  lesions  of  the  uveal  tract 
threaten  most  danger  to  the  second  eye.  None  of  the 
forms  of  uveal  inflammation  here  brought  under  no- 
tice have  followed  a  turbulent  course,  nor  have  they 
been  attended  with  any  acute  purulent  process.  Their 
character  has  been  insidious,  and  the  ciliary  body  has 
been  always  more  or  less  directly  involved. 

Glaucoma,  simply  as  such,  possesses  no  inherent 
power  to  awaken  sympathetic  disease.  When,  how- 
ever, in  the  last  stages  of  glaucoma,  cyclo-choroiditis 
sets  in,  and  the  eye,  hitherto  abnormally  hard,  becomes 
soft,  as  well  as  painful  over  the  ciliary  region,  the  sec- 
ond eye  becomes  as  much  endangered  sympathetically 
(Mooren,  v.  Arlt)  as  if  the  cyclo-choroiditis  had  its 
seat  in  a  non-glaucomatous  eye.  Moreover,  when  we 
see  a  case  of  sympathetic  ophthalmia  ascribed  to  a  de- 


ETIOLOGY.  47 

tachment  of  the  retina  in  the  first  eye,  or  to  a  haem- 
orrhage into  the  vitreous  humor,  we  should  incline 
toward  the  belief  that  a  cyclitis  had  supervened  upon 
the  primary  lesion,  and  had  itself  been  the  cause  of 
the  sympathetic  derangement;  as  Mooren  expressly 
argues,  in  the  case  of  retinal  detachment. 

Some  important  questions  which  we  next  have  to 
answer  are :  Does  purulent  inflammation  of  the 
uveal  tract,  also,  lead  to  sympathetic  ophthalmia  ? 
Can  sympathetic  ophthalmia  supervene  when  the  dis- 
ease of  the  first  eye  is  confined  to  the  iris  or  to  the 
choroid  alone,  produces  no  tenderness  over  the  ciliary 
region,  does  not  implicate  the  ciliary  body,  and  pur- 
sues an  unobtrusive  course  ?  Finally,  can  sympathetic 
ophthalmia  be  set  on  foot  without  lesion,  of  any  part 
whatever  of  the  uveal  tract  of  the  first  eye  ? 

It  has  been  generally  held  that  acute  purulent  in- 
flammation of  the  uveal  tract  .(better  termed  panoph- 
tfialmitis,  inasmuch  as  the  purulent  process,  accompa- 
nied by  great  swelling,  is  not  confined  to  the  uveal 
tract,  but  attacks  all  the  tunics  of  the  eye,  as  well  as 
the  vitreous  humor)  is  devoid  of  sympathetic  danger  to 
the  second  eye.  But  exceptional  cases  to  the  contrary 
have  been  reported  (Mooren,  Rossander).  Alt,  who 
ascertained  the  pathological  histories  of  one  hundred 
and  ten  eyes,  which  had  been  enucleated  on  account 
of  sympathetic  disease  (thirty-two  of  them  under  his 
own  observation),  found  that  twenty-one  of  the 


48  SYMPATHETIC   DISEASES   OF   THE   EYE. 

ber,  or  nineteen  per  cent.,  had  been  affected  with  typi- 
cal panophthalrnitis. 

Again,  it  has  been  established  that  sympathetic  af- 
fections may  occur  independently  of  any  disease  of 
the  ciliary  body,  and  even  without  any  well-defined 
lesion  of  the  uveal  tract.  Mooren  (1869)  cites  among 
the  diseases  which  may  lead  to  sympathetic  trouble, 
not  only  lesions  of  the  ciliary  body,  but  also  those  of 
the  conjunctiva,  sclerotica,  cornea,  iris,  choroid,  retina, 
and  lastly,  atrophy  of  the  globe.  It  should  be  added, 
however,  that  he  gives  the  most  etiological  importance 
to  cyclitis,  and  lays  particular  stress  upon  the  stretch- 
ing, or  laceration  of  the  ciliary  body,  whereby  a  sim- 
ple, minute  prolapse  of  the  iris  becomes  fraught  with 
danger  to  the  second  eye.  Peppmiiller  (1871)  re- 
ported a  few  cases  of  sympathetic  iritis  following 
simple  prolapse  of  the  iris,  without  symptoms  of 
cyclitis.  Liiders  (1872)  saw  a  case  of  injury  of  the 
e}re,  in  which  the  iris  and  anterior  capsule  of  the  lens, 
in  the  second  eye,  became  agglutinated  together  seven 
weeks  after  the  injury,  although  there  had  been  no 
sensitiveness  to  pressure  or  softening  of  the  injured 
eye. 

From  a  series  of  cases  brought  forward  by  Warlo- 
mont  (1872),  it  appeared,  in  one  case,  that  an  obstinate 
sympathetic  kerato-conjunctivitis  could  only  be  cured 
after  enucleation  of  the  first  eye,  which  had  been  for 
a  long  time  atrophied,  but  never  sensitive.  In  another 


ETIOLOGY.  49 

case,  that  of  a  veteran,  Warlomont  speaks  of  a  "  severe 
external  inflammation  of  the  right  eye  "  as  an  expres- 
sion of  sympathetic  disease,  although  the  stump  of  the 
other  eye,  which  had  been  destroyed  by  a  wound,  was 
"  perfectly  painless."  Other  cases  of  the  series  give 
abundant  evidence  that  phthisical  eyeballs,  which  have 
never  manifested  pain,  either  spontaneously  or  on 
pressure,  can,  nevertheless,  set  up  sympathetic  disease. 
Out  of  ninety  cases  of  sympathetic  ophthalmia,  pub- 
lished by  Rossander  in  1876,  two  originated  in  pain- 
less atrophy  of  the  fellow  eye  ;  and  out  of  ninety  sim- 
ilar cases,  reported  by  Vignaux  in  1877,  eight  could 
be  clearly  referred  to  the  same  condition.  The  state- 
ment, therefore,  is  not  entirely  warrantable,  that  when 
a  phthisical  eye  has  seemed  perfectly  quiescent,  a  de- 
posit of  bone  within  the  degenerated  globe,  irritating 
the  choroidal  tract  in  a  purely  mechanical  way,  and 
thereby  renewing  the  tenderness  and  pain  in  the  atro- 
phic  eye,  must  invariably  be  present  in  order  to  pro- 
duce sympathetic  disease. 

Cohn  (1871)  met  with  two  cases  of  sympathetic  im- 
pairment of  vision,  after  gunshot  wounds,  without 
symptoms  of  iritis,  or  cyclitis,  in  the  wounded  eye.  In 
one  of  his  cases  the  blind  and  offending  eye  had  un- 
dergone extensive  inflammation  of  the  choroid  and 
retina,  as  was  established  both  by  the  ophthalmoscope 
and  by  anatomical  examination  after  enucleation.  In 

the  other  case,  only  a  superficial  grazing  wound  from 
3 


50  SYMPATHETIC   DISEASES   OF   THE   EYE. 

a  fragment  of  shell,  had  been  inflicted  upon  the  eye, 
which  showed  no  internal  lesion  other  than  an  effusion 
of  blood  between  the  yellow  spot  of  the  retina  and  the 
choroid.  Brecht  (1874)  also  saw  a  case  in  which  dis- 
turbance of  sight  in  the  right  eye  hachbeen  transmitted 
sympathetically  from  its  injured  fellow,  which  latter, 
however,  was  "  absolutely  quiescent,  showed  no  trace 
of  unnatural  redness,  and  was  wholly  devoid  of  pain, 
either  spontaneously  or  under  pressure."  Pfliiger 
(1875)  traced  a  sympathetic  affection  of  the  one  eye 
to  a  wound  made  by  a  piece  of  stone  on  the  other, 
whilst  the  ciliary  body  of  the  injured  organ  seemed  to 
be  normal  in  every  respect.  He  also  reported  another 
case,  at  the  same  time,  in  which  an  eye  that  had  been 
destroyed  by  gonorrhoaal  ophthalmia,  proved  treacher- 
ous to  its  mate  a  few  weeks  later  ;  nevertheless,  when 
enucleated,  it  showed  no  sign  of  cyclitis,  but  simply 
an  inflammatory  infiltration  of  the  iris. 

Indeed,  if  we  give  credence  to  general  pathologico- 
anatomical  reports,  we  shall  not  need  to  search  out 
individual  cases  in  order  to  prove  that  sympathetic 
affections  of  the  eye  may  arise  quite  independently  of 
any  disease  of  the  ciliary  body.  Out  of  one  hundred 
and  ten  dissected  eyes  upon  which  Alt  reported,  m 
the  "  Archiv  fur  Augen-  und  Ohrenheilkunde,  1877," 
only  seventy-six  and  one-half  per  cent,  disclosed  any 
disease  of  the  ciliary  body.  Alt's  words  are  as  fol- 
lows: "The  iris  is  altered  in  sixty-eight  per  cent,  and 


ETIOLOGY.  51 

the  choroid  in  seventy-three  per  cent,  of  the  cases ;  so 
that  the  alterations  found  in  the  individual  parts  of 
the  uveal  tract  are  about  equally  distributed — those 
in  the  ciliary  body  very  slightly  exceeding  in  number 
those  in  each  of  flfte  other  parts." 

The  iitting  of  an  artificial  eye  upon  a  painless  stump 
has  been  known  to  develop  sympathetic  ophthalmia 
(Lawson,  Mooren,  Keyser) ;  and  reports  of  cases  are  at 
hand  where  the  insertion  of  an  artificial  eye  into  an 
orbit,  from  which  a  diseased  eye  had  been  removed  to 
abolish  sympathetic  irritation,  has  again  excited  the 
same  morbid  condition  (Salomon,  Warlomout).  Fi- 
nally, it  has  happened  that  the  enucleation  of  an  in- 
jured eye,  or  the  sequelae  of  the  operation,  performed 
for  the  especial  purpose  of  preventing  the  sympathetic 
implication  of  its  partner,  have  produced  the  appre- 
hended condition  (Mooren, -Colsmann);  or  that  the 
amelioration  first  following  the  enucleation  of  the 
offending  eye  has  afterward  disappeared,  and  the 
sympathetic  disturbance  been  reinstated  by  the  agency 
of  the  surgical  operation  itself  (Hasket  Derby). 

While  it  is  already  evident,  from  our  superficial 
notice  of  facts,  which  will  receive  further  considera- 
tion as  we  proceed,  that  manifold  forms  of  sympathetic 
disease  may  arise  without  the  presence  of  cyclitis  at 
the  time,  or  even  without  disease  of  any  portion  of  the 
uveal  tract,  there  remains  a  question  which  should  be 
answered  in  this  place.  Assuming  that  an  injured 


52  SYMPATHETIC   DISEASES    OF   THE   EYE. 

eye,  in  which  no  foreign  body  lies  concealed,  recovers 
perfectly,  so  far  as  we  can  ascertain  by  clinical  exam- 
ination, from  an  attack  of  severe  cyclitis — Recovers 
even  without  degenerating  into  a  state  of  atrophy — 
can  such  an  eye,  nevertheless,  excite  symptoms  of  sym- 
pathetic ophthalmia  in  the  fellow  eye  ?  This  question, 
be  it  understood,  can  only  be  put  where  the  cyclitis  is 
of  traumatic  origin  •  for  if,  after  the  recovery  of  an 
eye  from  spontaneous  cyclitis,  the  same  disease  be  set 
up  in  the  second  eye,  we  cannot  have  absolute  proof 
of  its  sympathetic  character.  In  answer  to  the  fore- 
going question,  I  communicate  the  following  case  : 

A  common  laborer,  sixty  years  of  age,  presented 
himself  at  the  Ophthalmic  Clinic,  October  3,  1875. 
He  stated  that  he  had  been  struck  on  the  right  eye, 
five  years  previously,  by  the  rebounding  branch  of  a 
tree,  and  that  the  sight  of  the  injured  eye  had  been 
instantaneously  lost.  He  also  complained  that  for 
about  five  years  preceding  his  appearance  he  had  been 
•unable  to  read  with  his  left  eye,  and  that  during  the 
last  year  the  sight  of  this  eye  had  rapidly  decreased. 
Both  eyes  showed  signs  of  cataract.  In  the  totally 
opaque  lens  of  the  right  eye  sparkling  crystals  of  cho- 
lesterine,  the  product  of  a  prolonged  process  of  degen- 
eration, justified  the  inference  that  the  cataract  had 
existed  even  a  considerable  period  previously  to  the 
infliction  of  the  injury.  In  the  left  eye  the  cataract 
was  of  more  recent  formation.  In  each  eye  the  per- 


ETIOLOGY.  53 

ception  of  light  corresponded  to  the  degree  of  opacity 
of  the  lens.  Both  cataracts  were  extracted  at  one 
sitting,  by  v.  Graefe's  method,  but  both  operations  met 
with  impediments  to  their  perfect  performance.  In 
the  right  eye  fragme'nts  of  the  lens  remained  behind 
in  the  capsule,  and  after  the  removal  of  the  speculum 
the  patient  squeezed  his  lids  together,  causing  escape  of 
vitreous  through  the  incision.  In  the  left  eye  vitreous 
humor  escaped  before  the  extraction  of  the  lens,  so 
that  the  latter  had  to  be  removed  with  the  spoon.  The 
right  eye  recovered  with  but  slight  inflammatory  re- 
action ;  the  left,  however,  developed  irido-cyclitis.  Of 
the  latter  (left)  organ,  it  was  noted,  on  October  3d : 
"  Cornea  and  aqueous  cloudy ;  pupil  occluded  by  ex- 
udation masses,  and  displaced  upward ;  ciliary  region 
painful ;  abnormal  softness  of  the  globe  ;  perception 
of  light."  And  again,  on  November  22d :  "  Tension 
of  eye  has  become  normal ;  the  ciliary  region  is  but 
slightly  sensitive  to  the  touch;  a  small  opening  has  been 
cleared  through  the  upper  and  outer  part  of  the  pupil ; 
the  patient  can  count  fingers,  with  this  eye,  at  a  dis- 
tance of  three  feet."  On  the  day  of  the  patient's  dis- 
charge, December  1st,  no  vestige  of  irritation,  sensi- 
tiveness, or  softness  remained  in  the  left  eye  ;  the 
cyclitis  had  completely  vanished,  and  vision  was  ^ 
normal.  In  the  right  eye  the  pupil  was  clear,  and  the 
fundus  of  the  globe  distinctly  visible,  but  floating 
opacities  in  the  vitreous  were  scattered  over  the  field 


54     t  SYMPATHETIC    DISEASES   OF   THE   EYE. 

of  vision.  These  opacities,  however,  could  not  be 
taken  as  evidence  of  cyclitis,  because  the  ciliary  body 
in  the  right  eye  had  not  been  painful,  and  the/ eyeball, 
after  the  week  first  following  the  operation,  had  been 
perfectly  free  from  injection,  painless,  and  of  normal 
tension.  It  possessed  one-eighth  of  the  normal  amount 
of  vision.  No  portion  of  the  iris,  in  either  eye,  was 
included  in  the  cicatrix.  The  patient  was  discharged 
in  the  forementioned  condition. 

On  January  18,  1876,  he  returned,  with  the  com- 
plaint that,  without  any  external  provocation,  his  right 
eye  now  suffered.  The  left  eye — the  one  that  had 
been  affected  with  cyclitis — had  not  been  in  the  least 
degree  painful  or  reddened  during  the  seven  weeks 
succeeding  the  discharge  of  the  patient,  and  on  the 
day  of  his  return  showed  no  trace  at  all  of  vascular 
injection,  or  of  tenderness,  on  pressure,  over  the  ciliary 
body  ;  its  vision  was  normal.  The  right  eye,  on  the 
other  hand,  showed  all  the  symptoms  of  a  highly  acute 
irido-cyclitis :  intense  episcleral  injection  environed 
the  corneal  border,  the  pupil  was  plugged  with  a 
mass  of  pus,  and  displaced  toward  the  place  of  inci- 
sion, the  globe  was  soft,  the  sight  was  dwindled  to  a 
mere  perception  of  light  and  darkness,  and  the  al- 
ready spontaneously  acute  pain  became  maddening 
when  pressure  was  made  over  the  ciliary  body. 

Here  an  operation,  performed  for  the  relief  of  cata- 
ract, had  excited  primary  cyclitis  in  the  left  eye.  The 


ETIOLOGY.  55 

disease,  however,  had  not  advanced  to  atrophy  of  the 
globe,  but  recovered  most  perfectly.  About  six  weeks 
later,  after  all  the  symptoms  of  the  previous  cyclitis 
had  disappeared  from  the  left  eye,  the  right  eye,  with- 
out any  external  cause,  and  without  any  symptoms  of 
the  reappearance  of  disease  in  the  eye  originally  af- 
fected, was  visited  with  an  attack  of  irido-cyclitis, 
greatly  surpassing  in  severity  the  primary  affection  of 
the  first  eye.  Thus,  even  after  the  complete  recovery 
of  one  eye  from  an  attack  of  cyclitis — a  recovery  not 
ending  in  atrophy  of  the  globe — the  other  eye  is  not 
thereby  absolutely  assured  of  immunity  against  an 
outbreak  of  sympathetic  ophthalmia. 


SECTION     III 


PATHOLOGY. 

IN  the  preceding  section  we  have  considered,  so  far 
as  is  practicable  in  the  preliminary  stage  of  our  work, 
the  various  individual  lesions  from  which  originate  the 

c? 

sympathetic  diseases  usually  grouped  under  the  name 
of  sympathetic  ophthalmia.  We  now  pass  to  a  more 
accurate  description  of  the  manifold  forms  in  which 
sympathetic  ophthalmia  appears.  The  more  knowl- 
edge we  acquire  of  this  class  of  affections  the  more 
multiplied  they  become.  Many  forms  of  ophthalmic 
disease,  whose  sympathetic  character  was  formerly 
and  even  but  recently  denied,  are  now  permanently 
settled  in  the  category  of  the  sympathetic  affections ; 
and  many  others,  which  are  still  involved  in  great 
doubt,  and  whose  acceptance  as  sympathetic  diseases 
is  properly  deferred,  may  hereafter  come  to  be  re- 
garded as  integral  links  in  this  dangerous  chain  of 
maladies. 

The  following  list  comprises  the  sympathetic  dis- 
eases of  the  eye  :  neuralgia  of  the  ciliary  nerves  ;  irri- 


PATHOLOGY.  57 

tation  of  the  retina,  and  of  the  optic  nerve ;  functional 
disturbance  of  the  retina;  inflammation,  severally,  of 
the  conjunctiva,  cornea,  and  choroid ;  inflammation  of 
the  uveal  tract,  with  or  without  participation  on  the 
part  of  the  ciliary  body,  so  that  there  may  be  both  a 
sympathetic  iritis  and  a  sympathetic  choroiditis,  with- 
out coexisting  cyclitis;  inflammation  of  the  retina, 
alone  or  in  conjunction  with  inflammation  of  the  cho- 
roid ;  inflammation  of  the  optic  nerve ;  glaucoma ; 
disease  of  the  vitreous,  and  of  the  lens.  Whether  all 
the  diseases  above  enumerated  are  legitimate  occu- 
pants of  the  list  of  sympathetic  affections  or  not,  we 
shall  see  in  the  sequel.  We  will  first  describe  the 
symptoms  of  sympathetic  irritation. 

The  ciliary  nerves  play  so  important  roles  in  the 
pathogeny  of  the  sympathetic  diseases  that,  before  dis- 
cussing the  subject  of  ciliary  neuralgia,  we  shall  de- 
vote a  few  lines  to  the  anatomical  description  of  these 
nerves. 

The  naso-ciliary  nerve  enters  the  orbit  through  the 
sphenoidal  fissure,  as  the  third  branch  of  the  ophthal- 
mic (sensitive)  division  of  the  trigeminus.  In  the  first 
part  of  its  course  it  lies  on  the  temporal  side  of  the 
optic  nerve  and  then  passes  obliquely  over  toward  the 
inner  wall  of  the  orbit,  between  the  optic  nerve  and 
the  superior  rectns  muscle.  As  it  crosses  the  optic 
nerve,  the  naso-ciliaris,  having  previously  given  off  the 

long  sensory  root  (radix  longa)  to  the  ciliary  ganglion, 
3* 


58  SYMPATHETIC    DISEASES   OF   THE   EYE. 

sends  off  from  one  to  three  filaments,  called  the  long 
ciliary  nerves,  which  run  straight  forward  to  the  eye- 
ball. The  ciliary  ganglion,  an  oblong  flattened  body, 
of  about  the  size  of  a  pin-head,  situated  between  the 
optic  nerve  and  the  external  rectus  muscle,  receives 
motor  fibres  (radix  brevis)  from  the  third  cranial 
nerve  (oculo-motor),  and  sympathetic  fibres  (radix 
sympathetica)  from  the  cavernous  plexus,  which  sur- 
rounds the  internal  carotid  artery.  The  three  roots 
just  mentioned  enter  the  posterior  border  of  the  gan- 
glion ;  whilst  the  anterior  border  gives  off  the  short 
ciliary  nerves,  which  then  pass  forward  to  enter  the 
eye.  The  long  and  short  ciliary  nerves  split  up  into 
fifteen  or  twenty  filaments  before  piercing  the  sclero- 
tica  around  the  periphery  of  the  optic  nerve,  and  di- 
viding still  further  as  they  advance,  run  forward,  be- 
tween the  choroid  and  sclerotica,  to  the  ciliary  muscle, 
in  which  they  form  a  fine  net-work,  from  which  nu- 
merous fibres  are  distributed  to  the  iris  and  cornea. 
The  ciliary  nerves,  by  reason  of  their  triple  composi- 
tion, confer  sensibility  upon  the  individual  parts  of  the 
eye,  as  well  as  motility  upon  the  ciliary  muscle,  the 
muscles  of  the  iris,  and  those  of  the  parietes  of  the 
vessels.  They  are,  moreover,  probably  endowed  with 
other  functions ,  which  will  engage  our  attention  far- 
ther on. 

In  connection  with  the  phenomena  of  sympathetic 
irritation,  it  should  be  remembered  that,  when  one  eye 


PATHOLOGY.  59 

becomes  inflamed  and  painful,  from  whatever  cause,  J 
the  other  can  no  longer,  as  a  general  rule,  be  used 
without  showing  unmistakable  symptoms  of  weariness. 
In  certain  inflammations — for  example,  those  phlycten- 
ular  lesions  of  the  cornea  which  accompany  the  so- 
called  scrofulous  affections  of  the  eye — the  photophobia 
of  the  diseased  eye  is  often  propagated  to  the  second, 
even  when  the  latter  is  perfectly  well,  so  that  both  eyes 
are  held  tightly  closed,  and  are  totally  incapacitated 
for  use.  Or,  if  the  case  does  not  exhibit  such  extreme 
symptoms  as  these,  the  second  eye,  in  consequence  of 
severe  irritation,  pain,  or  inflammation  of  the  first,  can- 
not be  employed  at  fine  work  without  soon  becoming 
tired  and  strained.  Every  considerable  effort,  perhaps 
for  a  longer,  perhaps  for  a  shorter  period,  causes  the 
second  eye  to  redden  and  become  irritable,  and  pro- 
vokes so  painful  sensations  as  seriously  to  impede 
its  function.  Indeed,  the  presence  of  a  particle  of  ? 
coal-dust  in  the  conjunctival  sac  of  the  one  eye  often- 
times suffices  to  set  up  a  whole  train  of  symptoms  of 
irritation  in  the  other. 

I  do  not  know  exactly  what  name  to  give  to  this 
striking  form  of  "  fellow-suffering  "  (as  it  were  "  sym- 
pathy ")  in  the  well  eye.  "  Sympathetic  irritation  "  is 
rather  objectionable,  for,  although  these  words  really 
define  the  state  of  things  as  just  described,  we  feel 
justified  in  reserving  this  expression  to  indicate  a  con- 
dition which  closely  borders  upon  sympathetic  ophthal- 


60  SYMPATHETIC    DISEASES    OF    THE    EYE. 

mia,  or,  indeed,  constitutes  its  preliminary  stage.  For, 
while  the  irritation  in  the  second  eye,  which  is  due  to 
pain  in  the  first,  usually  vanishes  with  the  subsidence 
of  the  original  pain,  or  very  simple  means,  such  as  the 
application  of  a  compress-bandage  to  the  diseased  eye, 
generally  relieves  the  spasmodic  closure  of  the  lids  in 
the  other,  and  enables  the  patient  to  separate  them 
freely,  this  simple  form  of  irritation  in  the  second  eye 
— and  here  is  the  main  point — may  persist  for  a  long 
time  without  danger  of  involving  tJie  organ  in  sub- 
stantial lesions. 

On  the  other  hand,  where  true  "sympathetic  irrita- 
tion "  is  present,  we  have  a  very  different  and  infi- 
nitely more  serious  state  of  matters.  For  example,  an 
eye  that  has  received  an  injury,  and  been  very  speedily 
attacked  with  irritation  and  inflammation,  may  excite 
almost  simultaneously,  in  the  opposite  eye,  so  acute  and 
painful  phenomena  that  it  is  by  no  means  uncommon 
to  hear  the  patients  complain  that,  for  the  first  day  or 
two  after  the  injury,  they  were  blind  in  both  eyes. 
When  the  inflammation  and  pain  subsequently  subside 
in  the  injured  eye,  the  second  becomes  again  quiescent 
and  serviceable,  and  remains  so  during  a  certain  inter- 
val. After  a  time,  however,  without  the  necessity  of 
any  especial  exacerbation  of  the  disease  in  the  first  eye, 
and  even  when  the  eyeball  is  no  longer  spontaneously 
painful,  but  only  painful  or  sensitive  to  the  touch,  the 
symptoms  of  irritation  may  reappear  in  the  second  eye, 


PATHOLOGY.  61 

so  that  it  becomes  sensitive  when  exposed  to  a  brighter 
light  than  usual,  and  fatigued  by  work  that  makes  but 
slight  demands  upon  its  accommodation.  The  patient, 
moreover,  may  occasionally  have  noticed,  even  from 
the  date  of  the  original  injury,  that  the  employment 
of  the  eye,  at  the  accustomed  distance  from  the  work, 
required  a  certain  effort,  which  was  relieved  by  holding 
the  work  farther  from  the  eye.  If  the  exercise  of  vi- 
sion is  persistently  prolonged,  the  eye  becomes  bathed 
in  tears,  pain  is  felt,  as  well  in  the  neighboring  regions 
as  in  the  eye  itself,  objects  are  seen  as  if  through  a  fog, 
and  if  the  work  be  pushed  to  an  extreme  limit,  the  eye 
becomes  utterly  disabled  for  a  time.  We  can,  further, 
often  learn  by  inquiry,  that  the  e}7e,  even  when  not 
taxed  by  exertion,  is  subject  to  temporary  obscuration 
of  its  field  of  vision.  Sometimes,  also,  during  this  irri- 
tative stage,  the  patient  complains  of  subjective  sensa- 
tions of  light,  in  the  form  of  sparks  or  flashes  of  fire. 

It  is  not  probable  that  these  symptoms  of  "  sympa- 
thetic irritation  "  depend,  in  their  early  stage,  upon 
textural  alteration  already  present  in  the  eye,  for  they 
promptly  disappear,  once  for  all,  as  soon  as  the  oppo- 
site eye  is  enucleated.  In  those  cases  in  which  the 
symptoms  of  irritation  do  not  cease  in  the  second  eye, 
notwithstanding  the  enucleation  of  the  injured  eye, 
but,  on  the  contrary,  give  place  to  those  of  violent  in- 
flammation, or  in  which  the  inflammation  is  lit  up  in 
the  sympathetic  eye  after  the  operation,  without  any 


62  SYMPATHETIC   DISEASES   OF   THE   EYE. 

preliminary  stage  of  irritation,  we  must  assume  that 
some  structural  disease,  without  salient  symptoms, 
had  already  invaded  the  second  eye  at  the  tiin«  when 
its  partner  was  removed;  or  that  some  insidious  dis- 
ease, which  did  not  depend  directly  upon  the  disease 
itself,  was  on  its  way  toward  the  second  eye,  and  could 
not  be  prevented  by  the  operation  ;  or,  finally,  that  the 
very  operation,  practised  for  the  relief  of  the  irritated 
eye,  was  itself  the  cause  of  the  sympathetic  oph- 
thalmia. 

If  no  textured  alteration  exists  in  the  second  eye  at 
the  time  of  the  "  sympathetic  irritation,"  the  latter 
must  be  ascribed  to  an  irritated  condition  of  the  ciliary 
nerves,  as  well  as  of  the  retina  and  optic  nerve.  Under 
such  circumstances,  it  appears  to  me  that  the  primary 
involvement  is  to  be  sought  for  in  the  retina,  inasmuch 
as  the  sensitiveness  of  the  eye  to  light,  the  quick  exhaus- 
tion of  the  retina  by  work,  the  transitory  obscuration 
of  the  field  of  vision,  and  the  subjective  sensations  of 
light,  all  point  toward  this  conclusion.  This  primary 
irritation  or  hyperaesthesia  of  the  retina  begets  a  sec- 
ondary or  reflex  neurosis  in  the  tract  of  the  ciliary 
nerves,  which  consist  in  great  part  of  sensory  filaments 
from  the  trigeminns.  In  consonance  with  this  view, 
we  do  not  believe  that  these  symptoms  depend  upon  a 
hidden  affection  of  the  muscles,  or  upon  asthenopia  of 
accommodation,  such  as  appears  in  consequence  of  the 
weakness  of  the  muscle  concerned  in  this  function. 


PATHOLOGY.  63 

is  it  our  opinion  that  the  holding  of  the  work  at  a  far- 
ther distance  than  usual  from  the  eye  is  so  much  a  proof 
that  the  affection  of  the  ciliary  muscle  is  the  primary 
one,  from  which  the  other  phenomena  of  sympathetic 
irritation  proceed,  as  that  the  ciliary  nerves  labor  under 
a  reflex  neurosis  propagated  from  the  primary  affec- 
tion of  the  retina,  so  that  the  contractions  of  the  ciliary 
muscle,  which  necessarily  provoke  pain  in  the  sensory 
filaments  of  the  sympathetic  nerves,  are  avoided  so  far 
as  possible. 

It  is  certainly  not  our  intention,  in  what  we  have  just 
said,  to  deny  that  primary  ciliary  neuralgia  may  ini- 
tiate sympathetic  disease.  This  affection,  which  has  its 
seat  in  the  ciliary  and  circumorbital  branches  of  the 
trigeminus,  is  characterized  by  violent  pain,  which  is  in- 
creased by  work,  so  long  as  work  is  possible,  as  well  as 
by  light ;  while,  at  the  same  time,  the  pain  does  not 
disappear,  even  if  the  patients  abandon  all  exertion  on 
the  part  of  the  eyes,  and  exclude  them  wholly  from 
the  influence  of  light.  Although  we  cannot  discover 
any  definite  lesion  of  the  eye,  it  is  evident  that  the 
neuralgia  of  the  eyeball  is  principally  located  in  the 
ciliary  body  (the  very  locality  of  the  chief  distribution 
of  the  nerves),  because  even  the  slightest  pressure  over 
the  ciliary  region  exaggerates  the  pain  to  an  intoler- 
able degree.  To  diagnosticate  cyclitis  under  these 
circumstances  would  be  quite  unjustifiable,  for  not  a 
trace  of  inflammation  exists  in  the  ciliary  body  a 


64  SYMPATHETIC    DISEASES    OF    THE    EYE. 

this  period,  but  simply  an  exquisitely  painful  and  vio- 
lent neuralgia  of  the  region  involved. 

The  same  irritative  condition  which  has  been  wit- 

/ 

nessed  in  the  tract  of  the  ciliary  nerves,  may  also  as- 
sume a  violent  type  in  the  retina  and  optic  nerve ;  so 
that  the  symptoms  of  sympathetic  irritation  vary  ac- 
cording to  the  functions  of  the  parts  involved.  The 
eye  affected  by  sympathy  may  exhibit  the  most  intense 
photophobia,  which,  in  turn,  may  develop  spasmodic 
action  of  the  orbicularis  muscle,  which  now  presses 
the  eyelids  so  tightly  together  that  the  patient  cannot 
open  his  eyes  at  all,  and  often  imagines  himself  to  be 
blind.  Douders  has  related  several  cases  of  this  form 
of  severe  sympathetic  irritation.  The  fact  that  the 
photophobia  disappears,  and  the  normal  power  of  vi- 
sion returns,  after  enucleation  of  the  opposite  eyeball, 
goes  to  prove  that  the  spasm  of  the  lids  was  due  to  the 
photophobia  alone.  We  are  here  to  remark,  moreover, 
that  the  sympathetic  irritation  of  the  retina  may  de- 
generate not  only  into  intense  photophobia,  but  into 
the  worst  phase  of  photopsia,  in  which  the  patient  is 
beset  with  subjective  sensations  of  the  most  torment- 
ing character.  We  have  already  mentioned  that  the 
patient  may  often  suffer  from  transitory  sensations  of 
light  during  the  ordinary  forms  of  sympathetic  irrita- 
tion ;  but  it  sometimes  happens  that  this  phenomenon 
reaches  an  extraordinary  height,  and  then  constitutes 
an  affection  of  the  most  serious  importance. 


PATHOLOGY.  65 

An  eyeball  is  wounded  by  a  penetrating  fragment  of 
a  percussion-cap.  About  one  year  afterward,  Alfred 
Graefe  enucleates  the  injured  eye  (although  its  vision 
is  but  slightly  deteriorated),  on  account  of  the  distress- 
ing subjective  sensations  in  the  other  eye,  which  are, 
however,  entirely  independent  of  any  demonstrable 
morbid  alteration,  while,  furthermore,  the  vision  of 
this  eye  is  absolutely  unimpaired.  Leber  examines 
the  enucleated  eye  and  discovers  the  fragment  of  cap 
adhering  firmly  to  the  inner  surface  of  the  apparently 
normal  ciliary  body.  That  portion  of  the  retina  which 
covers  the  ciliary  body,  and  is  called  the  pars  ciliaris 
retinae,  is  thickened  where  it  lies  applied  to  the  for- 
eign body,  and  a  new  formation  of  connective  tissue 
is  found  at  the  intra-ocular  extremity  of  the  optic 
nerve.  The  subjective  sensations  are  not  ameliorated 
by  the  operation,  but  reach  so  extreme  a  grade 
that  fears  are  entertained  for  the  life  of  the  patient. 
A  violent  degree  of  photopsia  may  certainly  ac- 
company simple  irritation  of  the  optic  nerve,  but  in 
that  case  the  photopsies  vanish  after  the  enucleation 
of  the  first  eye.  "Was  there  not,  therefore,  in  this  case 
of  Graefe's,  some  substantial  lesion  already  present  in 
the  sympathizing  eye  ?  We  shall  resume  this  question 
in  a  subsequent  place. 

But  photophobia  and  photopsies  are  not  the  only 
subjective  symptoms  of  irritation  of  the  optic  nerve 
and  retina ;  for  the  sympathy  may  express  itself  in  the 


66  SYMPATHETIC   DISEASES   OF   THE   EYE. 

form  of  distinct  functional  disturbances,  or  marked 
impairment  of  vision,  without  our  being  able  to  dem- 
onstrate the  presence  of  any  definite  structural  lesion 
in  either  the  percipient  or  the  conducting  apparatus 
of  the  eye.  We  should  first  mention,  in  connection 
with  this  form  of  sympathetic  irritation,  that  we  may 
observe  not  only  momentary  obscuration  and  limitation 
of  the  field  of  vision,  but  even  longer  intervals  of  sus- 
pension of  the  normal  function  of  the  retina.  Lie- 
breich  gives  instances  in  which  the  sympathetic  irrita- 
tion of  the  retina  manifested  itself  by  photophobia 
and  obscurations  of  the  field  of  vision,  which  lasted 
from  half  a  minute  to  a  minute,  appearing  and  disap- 
pearing at  regular  rhythmical  intervals.  A  still  more 
important  form  is  that  sympathetic  disturbance  of  vi- 
sion which  bears  some  relation  to  the  affection  to 
which  v.  Graefe  gave  the  name  of  anaesthesia  of  the 
retina  (proceeding  from  hypersesthesia),  while  Stef- 
fan  did  not  hesitate  to  call  it  genuine  hypercesthesia  of 
the  retina.  This  is  the  same  malady  for  which  Schil- 
ling proposed  the  name  of  "  contraction  of  the  field  of 
vision,  without  anatomical  lesion."  This  disease  is 
characterized,  on  the  one  hand,  by  a  diminution  of  the 
acuteness  of  central  vision,  and  on  the  other  by  anaes- 
thesia of  the  peripheral  portion  of  the  retina,  so  that 
the  field  of  vision  is  concentrically  contracted,  and  in 
a  very  uniform  manner  in  all  directions.  The  func- 
tion of  accommodation  may  also  be  impaired.  The 


PATHOLOGY.  67 

ophthalmoscope  reveals  nothing  abnormal,  either  in  the 
retina  or  in  the  optic  nerve.  Mooren  has  reported 
several  cases  of  this  form  of  sympathetic  disease,  and 
a  case  described  by  Brecht  (1874)  may  here  serve  for 
an  example. 

The  injured  left  eye  is  very  soft  at  the  time  of  the 
first  examination,  but  is  entirely  free  from  irritation. 
With  the  right  eye,  which  appears  normal,  the  patient 
can  count  fingers,  in  ordinary  light,  at  a  distance  of 
only  eight  feet.  If  the  eye  is  fixed  upon  a  given  point 
on  a  black-board  nine  inches  away,  it  cannot  distin- 
guish the  traces  of  a  piece  of  white  chalk  at  a  greater 
distance  than  two  and  a  half  inches  in  any  direction 
from  the  point  of  fixation.  The  field  of  vision  is, 
therefore,  concentrically  contracted,  so  that,  at  a  dis- 
tance of  nine  inches  from  the  eye,  it  embraces  only 
a  circle  two  and  a  half  inches  in  diameter,  described 
around  the  point  of  fixation.  There  are  no  pathologi- 
cal alterations  visible  with  the  ophthalmoscope.  After 
enucleation  of  the  left  eyeball,  both  central  and  per- 
ipheral vision  begin  to  show  a  decided  improvement, 
and  ten  weeks  after  the  operation,  central  acuteness  of 
vision,  as  well  as  the  peripheral  field  of  vision  and  the 
function  of  accommodation,  are  all  nearly  normal.  A 
black  splinter  of  metal  is  found  imprisoned  within  the 
enucleated  eyeball. 

Colin  has  reported  two  cases  which,  as  Leber  be- 
lieves, should  be  included  in  the  present  class  of  sym- 


68  SYMPATHETIC   DISEASES   OF   THE   EYE. 

pathetic  affections.  We  have  previously  alluded  to 
the  pathological  changes  in  eyes  that  have  been  sub- 
jected to  contusions  from  gunshot  wounds  (page  49), 
so  that  we  may  here  briefly  state  that  the  sympathetic 
disturbance  of  vision  in  Cohn's  cases  was  character- 
ized by  reduction  of  central  vision,  as  well  as  by  im- 
pairment of  the  function  of  accommodation,  and,  in 
one  of  the  cases,  by  severe  photopsies,  which  were  re- 
peatedly produced  by  the  most  trivial  exercise  of  the 
eye.  Cohn  says  nothing  about  the  state  of  the  field  of 
vision,  so  that  we  do  not  know  whether  it  was  con- 
tracted concentrically,  if  contracted  at  all.  The  enu- 
cleation  of  the  injured  eye  completely  dissipated  the 
sympathetic  troubles.  Hyperaesthesia  of  the  retina 
(not  necessarily  accompanied  by  photophobia  and  pho- 
topsia)  would  appear  to  be  the  cause  of  similar  sympa- 
thetic disturbances  of  vision  without  any  structural 
alterations  in  the  eye. 

We  now  turn  our  attention  from  the  manifold  as- 
pects of  sympathetic  irritation,  to  the  still  more  varied 
forms  of  sympathetic  inflammation.  In  what  causal 
relationship  with  the  inflammation  does  the  irritation 
stand?  Is  sympathetic  irritation  the  forerunner  of 
sympathetic  inflammation  ?  There  is  no  doubt  that 
the  complex  of  symptoms,  characterized  by  sensitive- 
ness of  the  eye  to  light  and  work,  slight  transitory 
congestion  of  the  pericorneal  region,  painful  sensa- 


PATHOLOGY.  G9 

tions  in  and  around  the  eye,  and  periodical  haziness  of 
the  field  of  vision,  is  to  be  regarded  in  the  light  of  a 
premonitory  stage  of  sympathetic  inflammation,  which 
now  lies  close  at  hand.  It  is,  however,  still  an  open 
question,  whether  the  uncomplicated  ciliary  neurosis, 
or  pure  photophobia  and  photopsia,  as  well  as  func- 
tional disturbances  of  the  retina  without  structural 
lesions  (although  these  affections  can,  as  a  matter  of 
fact,  continue,  simply  as  such,  for  a  long  time),  do  not 
finally  become  transformed,  on  the  one  hand  into 
cyclitis,  or  on  the  other  into  inflammation  of  the  retina 
or  of  the  optic  nerve.  It  would,  however,  be  incur- 
ring a  very  bold  risk  to  base  our  therapeutical  meas- 
ures on  the  assumption  that  such  a  state  of  irritation 
never  becomes  transmuted  into  one  of  inflammation, 

In  proceeding  to  consider  the  different  manifesta- 
tions of  sympathetic  inflammation,  as  it  affects  the  in- 
dividual parts  of  the  eye,  we  must  first  notice  the  cornea. 
Sympathetic  keratitis  is  described  by  Warlomont  as 
being  marked  by  inflammatory  cloudiness  of  the  super- 
ficial layers  of  the  cornea,  and  a  profuse  development 
of  vessels  therein,  conjoined  with  pain  in  the  periorbital 
region  and  head,  on  the  affected  side,  together  with  in- 
tense monocular  conjunctivitis.  We  have  already  re- 
ferred to  a  case  in  which  an  eye  was  destroyed  by  the 
thrust  of  a  cow's  horn.  The  eyeball  was  reduced  to  a 
small  stump,  and,  for  ten  years  afterward,  remained 
painless  and  inoffensive  to  its  mate.  After  that  period 


70  SYMPATHETIC   DISEASES   OF   THE    EYE. 

keratitis  appeared  in  the  second  eye,  underwent  con- 
tinual relapses  during  several  years,  and  was  rebellious 
to  all  treatment  until  the  atrophic  stump  was  finally 
enucleated,  when  the  sympathetic  affection  disap- 
peared, as  if  by  magic.  In  further  proof  of  the 
sympathetic  nature  of  the  disease,  it  may  be  stated 
that  an  artificial  eye,  worn  after  the  operation,  excited 
inflammation  of  the  palbebral  conjunctiva,  with  which 
it  came  in  contact,  as  well  as  a  fresh  outbreak  of 
vascular  keratitis  in  the  remaining  eye,  and  that  when 
the  artificial  eye  was  thrown  aside  and  poultices  were 
applied  to  the  inflamed  cavity  for  several  days,  the 
sympathetic  keratitis  disappeared  without  the  neces- 
sity of  having  recourse  to  any  other  treatment. 

Rossander  has  reported  one  case  of  sympathetic  in- 
termittent keratitis;  while  Galezowski,  Bheindorf, 
Ledoux  and  Yignaux  have  seen  cases  of  sympathetic 
Jcerato-iritis.  Vignaux  (1877)  observed  the  latter  condi- 
tion eight  times  among  ninety  cases  of  sympathetic  oph- 
thalmia. "  In  this  form  of  keratitis,"  writes  the  last- 
named  observer.  "  the  cornea  becomes  the  seat  of  a  very 
diffuse  (sometimes  circumscribed)  infiltration,  which 
becomes  transformed  into  superficial  ulcerations :  while 
one  ulcer  heals,  another  makes  its  appearance.  The 
iris  always  becomes  implicated  in  the  inflammatory 
process,  and  pus  is  occasionally  found  in  the  anterior 
chamber.  The  ciliary  pain  is  acute,  and  the  photo- 
phobia is  almost  as  excessive  as  that  which  we  meet 


PATHOLOGY.  71 

with  in  scrofulous  inflammation  of  the  cornea."  We 
must  especially  notice  that  tne  ciliary  body  does  not 
seem  to  be  affected  during  these  forms  of  inflamma- 
tion, which  are  generally  milder  than  all  others.  Al- 
though not  infrequently  met  with  by  French  writers 
(constituting  as  they  do  almost  ten  per  cent,  of  Vig- 
naux's  series  of  cases),  they  are,  nevertheless,  seldom 
reported  in  German  medical  literature.  Perhaps  this 
hiatus  has  hitherto  been  due  to  a  lack  of  vigilance  ill 
observation. 

Sympathetic  ophthalmia  may  also  manifest  itself  by  a 
genuine  attack  of  sclerotitis,  unaccompanied  by  inflam- 
mation of  the  ciliary  body.  Rossander,  for  instance, 
mentions  two  such  cases,  in  which  sympathetic  sclero- 
titis  was  happily  relieved  by  the  enucleation  of  the  in- 
jured eye. 

Of  the  various  sympathetic  inflammatory  processes 
that  may  affect  the  individual  structures  of  the  eye, 
those  which  primarily  have  their  seat  in  the  uveal 
tract  vastly  exceed  all  others  in  importance,  and  they 
are,  further,  the  ones  which  most  often  come  under 
observation  and  treatment.  By  reason,  therefore,  of 
their  great  significance  and  frequency,  as  well  as  their 
destructive  effects,  it  is  of  the  first  moment  that  they 
should  be  promptly  and  accurately  diagnosticated,  with 
a  view  to  their  timely  and  appropriate  treatment. 

Iritis  serosa  is  the  least  severe  of  the  different  forms 
of  sympathetic  inflammation  of  the  uveal  tract.  Sup- 


72  SYMPATHETIC   DISEASES    OF    THE   EYE. 

pose  that  the  patient  complains  of  a  slight  failure  of 
vision  in  his  well  eye,  whilst  the  opposite  eye,  which 
had,  perchance,  been  destroyed  by  an  injury,  is  still 
pairjful,  or,  perhaps,  only  sensitive  to  pressure.  The 
characteristic  symptoms  of  sympathetic  irritation  are 
not  present :  the  worst  that  the  patient  complains  of 
is,  that  for  some  time  past  every  object  has  appeared 
to  be  covered  with  a  thin  cloud.  If  the  medical  at- 
tendant is  not  alert,  the  actual  pathological  process 
may  be  overlooked,  and  perhaps  mistaken  for  a  sym- 
pathetic functional  disturbance  of  the  retina.  Careful 
investigation,  however,  by  daylight,  or  by  the  oblique 
illumination  of  the  eye  (the  image  of  a  lamp-flame 
being  projected  upon  the  cornea  by  a  strong  convex 
lens),  will  reveal  small,  grayish,  punctated  opacities  on 
the  posterior  surface  of  the  lower  half  of  the  cornea, 
while,  if  the  pupil  be  illuminated  by  the  ophthalmo- 
scope (the  patient  looking  downward),  its  area  will 
appear  to  be  filled,  as  it  were,  with  fine  dust,  inter- 
spersed here  and  there  with  small,  dark  specks,  vary- 
ing in  size  from  a  pin-head  to  almost  microscopical 
minuteness.  It  may,  indeed,  happen  that  with  the 
unaided  eye,  or  even  with  oblique  illumination,  nothing 
unusual  can  at  first  be  discovered,  and  that  it  will  re- 
quire the  use  of  the  ophthalmoscope  before  the  punc- 
tated appearance  of  the  cornea  can  be  accurately 
recognized  by  the  incident  light.  We  shall,  moreover, 
now  begin  to  notice  that  although  the  eye  had  been 


PATHOLOGY.  73 

pale  before  the  examination,  the  irritation  incident  to 
this  procedure  has  of  itself  sufficed  to  provoke  a  faint 
rosy  zone  of  episcleral  injection  around  the  margin  of 
the  cornea.  We  shall  also,  perhaps,  see  that  the  pupil, 
although  perfectly  free,  and  nowhere  adherent  to  the 
anterior  capsule,  does  not  react  so  promptly  to  the  in- 
fluence of  light  and  shade,  as  when  in  a  normal  con- 
dition, and  that,  although  a  comparison  with  the 
other  eye  may  not  now  be  practicable,  the  pupil  is 
evidently  rather  larger,  and  the  anterior  chamber 
much  deeper  than  in  the  mate.  Sensitiveness  of  th'j 
ciliary  body  is  not  necessarily  educed  by  pressure. 
The  tension  of  the  globe  is,  on  the  whole,  quite  normal : 
sometimes  it  may  be  increased,  but  it  is  never  dimin- 
ished. Such,  then,  are  the  most  simple  indications  of 
serous  iritis. 

We  have  already  mentioned  that  the  tine  opacities 
in  iritis  serosa  are  situated  on  the  posterior  surface  of 
the  cornea.  We  assume  that  there  is  an  increased  ex- 
udation of  serum  (with  the  addition  of  pus-corpuscles 
and  coagulable  material)  from  the  iris  into  the  anterior 
chamber,  which  latter  is  consequently  deepened,  owing 
to  the  pressing  backward  of  the  iris  and  lens  by  the 
superabundant  fluid.  The  pus-corpuscles  and  small 
masses  of  coagulable  lymph  gravitate  downward,  and 
become  deposited  on  the  posterior  surface  of  the  cor- 
nea ;  so  that  we  need  not  be  at  all  surprised  at  the 

general  absence  of  these  "  precipitates  "  on  the  upper 
4 


74  SYMPATHETIC   DISEASES    OF   THE   EYE. 

portion  of  the  cornea.  The  presence  of  these  puncti- 
form  deposits  is  pathognomonic  of  iritis  serosa.  Al- 
though, strictly  speaking,  they  are  not  always  deposits 
precipitated  from  the  aqueous  humor,  nevertheless, 
the  difference  in  their  origin  does  not  alter  their  diag- 
nostic value.  If  we  puncture  the  anterior  chamber 
and  catch  in  a  watch-glass  a  portion  of  the  contents, 
together  with  some  of  the  precipitates  upon  the  pos- 
terior surface  of  the  cornea,  we  may  experimentally 
convince  ourselves  that  these  opacities  are,  as  a  rule, 
actual  deposits,  consisting  of  particles  of  coagulated 
fibrin,  enclosing  pus-corpuscles  in  greater  or  less  num- 
ber. On  the  other  hand,  it  has  been  found,  during  his- 
tological  investigations,  that  these  punctiform  spots  on 
the  posterior  surface  of  the  cornea  may  also  be  caused 
by  inflammatory  changes  in  the  epithelial  lining  of  the 
membrane  of  Descemet,  and  even  in  the  posterior 
laminae  of  the  proper  corneal  substance.  It  need  not, 
therefore,  surprise  us  that  these  "  precipitates  "  should 
now  and  then  be  observed,  not  only  on  the  lower  por- 
tion of  the  posterior  corneal  surface,  but  also  opposite 
the  pupil,  and  sometimes  even  scattered  over  the  upper 
half  of  the  cornea.  Nevertheless,  true  inflammation 
of  the  membrane  of  Descemet,  or  genuine  keratitis 
postica,  is  always  to  be  regarded  as  characteristic  of 
the  serous  form  of  iritis,  inasmuch  as  it  is  directly 
excited  by  the  morbid  and  irritating  contents  of  the 
anterior  chamber.  It  is  chiefly  the  accompanying 


PATHOLOGY.  75 

turbidity  of  the  aqueous  which  causes  the  hazy  ap- 
pearance of  all  objects  seen  with  the  affected  eye. 

It  is  important  to  note,  in  this  connection,  that  while 
sympathetic  iritis  serosa  usually  appears  under  the 
unobtrusive  symptoms  above  described,  those  forms  of 
this  affection  which  are  independent  of  a  sympathetic 
origin,  are  wont  to  be  more  distinctly  and  prominently 
expressed.  In  the  latter,  we  not  unfrequently  notice 
very  marked  pericorneal  injection,  extreme  deepening 
of  the  anterior  chamber,  and,  instead  of  the  fine  punc- 
tated exudation  on  the  membrane  of  Descemet,  coarse, 
grayish,  or  even  yellow,  nodules,  as  large  as  pin-heads 
or  hemp-seeds.  It  should,  moreover,  be  distinctly 
borne  in  mind  that  we  are  not  directly  to  diagnosti- 
cate iritis  serosa,  on  account  of  the  presence  of  nod- 
ules of  exudation,  but  to  look  about  for  other 
alterations  in  the  eye.  If,  for  example,  we  have 
simultaneously,  an  inflammatory  adhesion  of  the  mar- 
gin of  the  pupil  to  the  anterior  capsule  of  the  lens,  it 
would  be  wrong  to  call  the  case  one  of  iritis  serosa. 
The  precise  difference  between  a  serous  and  a  plastic 
iritis  lies  in  this  fact,  that  in  the  serous  form  there  is 
not  a  sufficient  degree  of  plastic  inflammation  to  effect 
any  such  adhesion  between  the  edge  of  the  pupil  and 
the  capsule.  On  the  other  hand,  however,  it  is  by  no 
means  uncommon,  in  a  case  of  violent  iritis  plastica, 
to  observe  flocculent  masses  of  pus  or  lymph  floating 
about  in  the  aqueous  humor,  as  well  as  considerable 


76  SYMPATHETIC   DISEASES    OF   THE    EYE. 

proliferation  of  the  epithelial  cells  of  the  membrane 
of  Descemet. 

It  is  further  important  for  us  to  insist  upon  an  ac- 
curate discrimination  between  the  plastic  and  the 
serous  form  of  sympathetic  iritis.  Sympathetic  iritis 
plastica  closely  simulates,  at  the  outset,  common  plastic 
iritis,  which,  as  a  rule,  leads  to  only  partial  adhesions 
of  the  pupillary  edge  to  the  anterior  capsule,  but  not 
tc  a  marked  agglutination  of  the  posterior  surface  of 
the  iris  to  the  capsule  of  the  lens.  Sympathetic  iritis 
plastica  is,  on  the  contrary,  very  prone  to  develop  into 
that  more  severe  grade  of  iritis  in  which  the  adhesion 
rapidly  involves  the  whole  circumference  of  the  pupil- 
lary border,  so  as  to  shut  off  all  communication  be- 
tween the  anterior  and  posterior  chambers,  producing 
the  condition  technically  termed  exclusion  of  the  pupil. 
Under  these  circumstances,  the  central  portion  of  the 
anterior  capsule,  opposite  the  pupil,  may  still  remain 
perfectly  clear,  or,  at  the  most,  be  covered  with  so  scanty 
a  morbid  product  as  not  essentially  to  obstruct  the  pas- 
sage of  the  rays  of  light.  "When,  on  the  other  hand, 
the  pupil  is  filled  with  a  thick  pseudo-membrane,  or 
even  with  a  dense  plug  of  exudation,  so  that  the  pu- 
pillary area  is  completely  abolished,  the  condition  is 
called  occlusion  of  the  pupil.  As  the  exclusion  of  the 
pupil  may  exist  without  its  occlusion,  so,  conversely,  oc- 
clusion may  not  necessarily  involve  exclusion.  For  it 
is  easy  to  comprehend  that  a  false  membrane  may 


PATHOLOGY.  77 

wholly  Cover  the  pupil  without  necessitating  a  con- 
tinuous adhesion  between  the  entire  circumference  of 
the  pupil  and  the  anterior  capsule;  so  that,  at  one 
point  or  another,  beneath  the  edge  of  the  membrane, 
an  opening,  however  small,  may  still  remain,  and  so 
preserve  the  communication  between  the  two  chambers. 
Occlusion  of  the  pupil,  although  obstructing  the 
passage  of  the  rays  of  light,  may  cause  no  real  dam- 
age to  the  eye  itself  ;  but  exclusion  of  the  pupil,  while 
presenting  no  direct  barrier  to  the  vision,  very  fre- 
quently destroys  the  affected  eye.  We  may  conceive 
that  the  aqueous  humor  is  secreted  by  the  ciliary  pro- 
cesses and  iris,  or  perhaps  only  by  the  posterior 
surface  of  the  latter.  We  know,  besides,  that  the 
aqueous  normally  finds  its  way  out  of  the  anterior 
chamber,  by  filtration  and  diffusion  into  the  veins 
immediately  adjacent  to  its  periphery.  If,  now,  the 
communication  between  the  anterior  and  posterior 
chambers  is  abolished  by  exclusion  of  the  pupil,  the 
fluid  secreted  into  the  posterior  chamber,  from  the 
ciliary  processes  and  the  posterior  surface  of  the  iris, 
is  deprived  of  its  normal  means  of  escape  into  the  an- 
terior chamber,  and  then  into  the  pericorneal  veins,  as 
well  as  into  the  sinuses  of  the  ligamentum  pectinatum 
iridis,  so  that  an  abnormal  accumulation  of  aqueous 
takes  place  in  the  posterior  chamber.  It  happens, 
therefore,  as  soon  as  the  pressure  of  the  fluid  in 
the  posterior  chamber  exceeds  that  in  the  anterior, 


78  SYMPATHETIC   DISEASES    OF   THE   EYE. 

that  the  inequality  manifests  itself  by  the  bulging  for- 
ward of  the  iris  into  the  anterior  chamber,  except  at 
those  points  where  it  is  held  back  by  the  adhesions. 
The  protrusion  forward  of  the  periphery  of  the  iris, 
accompanied  by  a  crater-like  depression  of  its  pupil- 
lary edge,  is,  therefore,  a  sign  of  exclusion  of  the  pupil. 
So  long  as  this  phenomenon  is  absent  we  cannot  diag- 
nosticate exclusion  of  the  pupil ;  for,  even  with  the 
assistance  of  mydriatics,  we  are  unable  to  declare 
positively  that  some  minute  hole  does  not  exist,  at  one 
point  or  other,  around  the  apparently  completely  ad- 
herent margin  of  the  pupil. 

Now,  this  imprisonment  of  the  aqueous  humor  be- 
hind the  iris,  with  the  jutting  forward  of  the  periph- 
ery of  the  latter  membrane,  almost  invariably  leads  to 
a  complex  set  of  symptoms,  which  are  comprised  un- 
der the  name  of  secondary  glaucoma,  in  which,  with 
more  or  less  violent  attacks  of  inflammation,  the  ten- 
sion of  the  eye  increases  and  vision  diminishes;  or  the 
globe  remains  hard,  while  vision  gradually  decreases 
to  utter  blindness,  without  any  intercurrent  inflam- 
matory phenomena  whatever.  The  extinction  of  vi- 
sion then  depends  upon  a  lesion  of  the  optic  nerve, 
producing  its  total  atrophy.  Glaucoma  is  that  af- 
fection of  the  eye  which,  with  evident  hardness  of  the 
globe,  and  with  or  without  inflammatory  exacerbations, 
leads  to  blindness.  When  the  glaucoma  depends 
upon  some  affection  previously  present  in  the  interior 


PATHOLOGY.  79 

of  the  affected  eye — as  in  our  case,  for  example,  upon 
a  bulging  iris,  produced  by  accumulation  of  fluid 
behind  it — the  disease  is  called  secondary  glaucoma. 
It  follows,  therefore,  that  secondary  glaucoma  may 
sometimes  occur  'in  a  sympathetically  diseased  eye, 
and  cannot  always  be  regarded  as  a  part  of  the  sym- 
pathetic process.  For  when  sympathetic  iritis  plastica  is 
followed  by  continuous  circular  adhesions  (exclusion 
of  the  pupil),  and  finally  produces  secondary  glaucoma, 
the  latter  disease  depends  wholly  upon  the  adhesions, 
aud  not  at  all  upon  the  sympathetic  origin  of  the  latter. 
We  should  here  incidentally  remark  that  an  inclina- 
tion prevails,  whenever  sympathetic  ophthalmia  is  met 
with,  to  diagnosticate  a  cyclitis  /  or  when  the  signs  of 
a  plastic  cyclitis  are  wanting,  to  find,  at  least,  a  serous 
cyclitis.  But  we  are  not  of  those  who  believe  that 
the  bulging  forward  of  the  periphery  of  the  iris,  in 
sympathetic  ophthalmia,  or  in  secondary  glaucoma, 
furnishes  sufficient  ground  for  inferring  the  existence 
of  a,ny  sort  of  cyclitis,  inasmuch  as  aji  analogous  con- 
dition of  the  iris  may  likewise  be  developed  in  com- 
mon inflammations  of  this  membrane  (which  are  quite 
independent  of  any  sympathetic  foundation),  without 
properly  exciting  any  suspicion  of  even  serous  cyclitis. 
The  idea  of  assuming  the  presence  of  cyclitis,  in  the 
generality  of  cases  of  sympathetic  ophthalmia,  is  just 
as  unnecessary  as  the  possibility  of  establishing  the 
fact  of  its  presence  is  questionable. 


80  SYMPATHETIC   DISEASES    OF   THE   EYE. 

The  mildest  form  of  sympathetic  disease  of  the  uveal 
tract  is  serous  iritis  / plastic  iritis  comes  next  in  order 
of  severity,  chiefly  on  account  of  the  annular/posterior 
synechise,  or  exclusion  of  the  pupil,  to  which  it  is  so 
prone  to  give  rise  ;  but  incomparably  the  most  serious 
manifestation  of  sympathetic  uveal  disease  is  the  so- 
called  iritis  maligna,  which  is  nothing  else  than  a 
plastic  irido-cyclitis.  In  iritis  serosa,  adhesions  do  not 
commonly  take  place  between  the  iris  and  anterior 
capsule ;  in  plastic  iritis  adhesions  occur,  but  they  are 
as  a  rule,  limited  to  the  pupillary  border  of  the  iris  ; 
whilst  iritis  maligna  is  characterized  by  extensive  ag- 
glutination of  the  posterior  surface  of  the  iris  to  the 
anterior  capsule  of  the  lens.  Inasmuch  as,  in  iritis 
maligna,  choroiditis  is  almost  always  superadded  to 
the  irifjfr-cyclitis,  and  the  integrity  of  the  retina  be- 
comes thereby  threatened,  sympathetic  nveitis  attains, 
in  iritis  maligna,  its  culminating  degree  of  severity. 
For  when  the  iris,  ciliary  body,  and  choroid  are  all 
involved  in  the  inflammatory  process,  the  eyeball  is 
usually  consigned  to  atrophy. 

It  is  not  necessary  for  us  at  this  point  to  sketch  the 
symptoms  of  sympathetic  iritis  maligna,  inasmuch  as 
we  have  already  (pages  26,  27,  and  28)  clearly  de- 
scribed irido-cyclitis,  as  well  as  irido-cyclo-choroiditis, 
of  the  primarily  affected  eye,  as  they  occur  either  spon- 
taneously or  in  connection  with  injuries;  and  the  sym- 
pathetic forms  do  not  differ  materially  froin  the  primary, 


PATHOLOGY.  81 

except  in  the  more  frequent  opportunities  we  have  for 
observing  the  former.  In  other  words,  the  genuine 
form  of  the  disease  in  question  is  much  oftener  seen  in 
the  eye  affected  by  sympathy,  than  in  the  eye  originally 
affected,  in  which  latter  the  regular  type  of  the  disease 
is  frequently  obliterated  by  the  immediate  effects  of 
the  injury. 

What  relationship  and  mutual  dependences  do  we 
find  among  the  different  forms  of  sympathetic  iritis  f 
What  are  their  course  and  issue  ?  It  is  true  that  iritis 
maligna  is  more  frequently  met  with  than  the  serous 
or  the  plastic  form  of  iritis  ;  nevertheless,  the  two  last- 
named  species  of  this  malady  are  not  so  rare  as  is 
commonly  supposed.  Statistical  inflammation  touch- 
ing the  comparative  frequency  of  iritis  serosa  is  not 
easily  obtainable,  because  the  great  majority  of  indi- 
viduals who  are  affected  with  this  variety  of  sympa- 
thetic disease  certainly  do  not  come  under  the  notice 
of  a  medical  attendant.  It  may  be  inquired  how  this 
is  possible  ?  Is  not  serous  iritis  merely  a  forerunner 
of  the  more  important  kinds  of  inflammation  of  the 
iris?  Is  it  not  the  pioneer  of  iritis  maligna?  We 
must  promptly  answer  this  question  in  the  negative. 
Then,  again,  if  the  serous  form  of  iritis  were  transmu- 
table  into  iritis  maligna,  we  should  probably  find  few 
opportunities  to  observe  the  former,  for  the  reason 
that  only  the  severer  grades  of  iritis  are  likely  to  bring 

the  sufferer  under  professional  observation.    The  recog- 
4* 


82  SYMPATHETIC   DISEASES   OF   THE    EYE. 

nition,  therefore,  of  sympathetic  iritis  serosa,  as  a  dis- 
tinct affection,  is  not,  in  some  respects,  of  great  practical 
moment.  It  is,  however,  of  importance  for  us  to  know 
that  iritis  serosa  has  no  inherent  tendency  to  lapse  into 
the  worst  forms  of  iritic  inflammation.  Whenever  a 
surgeon  enucleates  an  injured  eye,  on  account  of  sym- 
pathetic serous  iritis,  and,  upon  subsequently  seeing 
amelioration  of  the  symptoms,  flatters  himself  that  his 
well-timed  interference  has  happily  prevented  a  sym- 
pathetic plastic  irido-cyclitis,  and  blindness  of  both 
eyes,  he  has,  in  all  probability,  been  the  victim  of  a 
self-pleasing  error.  However,  we  do  not  here  desire  to 
anticipate  a  discussion  of  the  indications  for  enuclea- 
tion,  but  only  parenthetically  to  remark,  that  iritis 
serosa  has  nothing  in  common  with  iritis  maligna, 
and,  as  a  very  general  rule,  runs  a  favorable  course 
\vithoutextirpationofthe  eye  first  affected ;  and  fur- 
thermore, that  when  a  case  of  sympathetic  iritis  serosa 
has  degenerated  into  a  worse  form  of  iritis,  after  the 
enucleation  of  the  first  eye,  the  operation  itself  has, 
in  all  probability,  been  the  cause  of  the  new  sympa- 
thetic process. 

The  relationship  which  exists  between  iritis  plastica 
and  iritis  maligna  calls  for  some  comment.  It  is  very 
generally  stated  in  connection  with  iritis  maligna  that 
adhesions  between  the  greater  portion  of  the  posterior 
surface  of  the  iris  and  the  anterior  capsule  of  the  lens 
need  not  be  present  in  order  to  establish  the  diagnosis, 


PATHOLOGY.  83 

but  that,  in  the  beginning,  the  adhesion  may  be  limited 
to  the  pupillary  border,  while  the  periphery  of  the  iris 
is,  at  the  same  time,  bulged  forward  by  the  serum 
confined  behind  it.  It  is  further  averred  that  at  a 
later  stage  of  the  affection  the  serous  gives  place 
to  a  plastic  exudation,  which  then  firmly  and  exten- 
sively glues  together  the  iris  and  anterior  capsule,  and, 
by  subsequent  contraction,  retracts  the  periphery  of 
the  iris.  I  will  here  place  no  significance  upon  the  fact 
that  I  have  never,  in  my  personal  experience,  witnessed 
this  transition  from  a  protrusion  to  a  retraction  of  the 
periphery  of  the  iris ;  but  I  must  openly  say,  that 
when  I  see  total  circular  posterior  adhesions,  with 
bulging  of  the  periphery  of  the  iris,  in  a  case  of  sym- 
pathetic ophthalmia,  I  do  not  think  of  diagnosticating 
iritis  maligna,  but  only  the  common  form  of  plastic 
iritis  with  exclusion  of  the  pupil,  especially  as  the  ten- 
sion of  the  eyeball  so  affected  is  not  diminished,  but 
is  either  normal  or  augmented.  Such  an  iritis,  if 
secondary  glaucoma  should  not  supervene,  might  run 
a  relatively  favorable  course.  Nevertheless,  I  do  not 
like  to  take  the  risk  in  such  cases,  but  let  the  bulging 
of  the  iris  be  to  me  the  signal  for  surgical  interference. 
It  is  quite  a  matter  of  course  that  errors  of  diagnosis 
may  sometimes  occur  in  these  cases,  for  the  iris  may 
not  only  be  thrust  forward  by  the  aqueous  humor  im- 
prisoned in  the  posterior  chamber,  but  likewise,  by 
extensive  plastic  exudation  in  the  same  locality,  as  I 


84:  SYMPATHETIC    DISEASES    OF    THE    EYE. 

was  once  convinced  upon  dissection  of  an  eye.  In  the 
case  here  instanced,  it  was  easy  to  see  how  the  iris  might 
have  first  been  bulged  forward,  and  then  retracted  at 
its  periphery  by  the  shrinking  of  the  exudation. 

The  course  of  iritis  maligna  varies  according  to  the 
different  structures  involved  in  the  inflammatory  pro- 
cess. Sometimes  it  is  almost  wholly  confined  to  the 
iris  and  ciliary  body,  so  that  the  integrity  of  the  vitre- 
ous and  choroid  (and  consequently  of  the  retina),  is 
mostly  spared.  The  eye,  under  the  latter  condition  of 
things,  retains  perfectly  or  tolerably  well  its  normal  ten- 
sion (even  when  the  inflammation  has  covered  the  pupil 
with  a  pseudo-membrane),  is  frequently  promptly  sen- 
sitive to  light  and  shade,  and  in  cases  where  the  pupil 
remains  clear,  or  is  obstructed  by  only  a  thin  film, 
preserves  a  corresponding  degree  of  vision.  The 
majority  of  cases  of  iritis  maligna,  however,  terminate 
in  atrophy  of  the  globe,  on  account  of  the  consecutive 
inflammation  of  the  choroid,  so  that  perception  of 
light  is  either  totally  extinguished,  or  reduced  to  an 
insignificant  amount. 

In  the  form  of  sympathetic  ophthalmia  now  under 
consideration  (plastic  irido-cyclitis),  we  sometimes  no- 
tice a  remarkable  phenomenon,  which  is  of  great  value 
in  connection  with  the  patkoyeny  of  this,  as  well  as  of 
other  sympathetic  affections  in  which  it  occurs,  and 
which  will,  therefore,  be  further  discussed  in  another 
place. 


PATHOLOGY.  •  85 

» 

It  consists  of  the  manifestation  of  pain,  either  spon- 
taneously or  on  pressure,  at  a  spot  on  the  sympathetic 
eye,  corresponding  symmetrically  to  a  point  on  the 
injured  eye,  which  is  still  spontaneously  painful,  or 
painful  only  to  the  touch.  If,  for  illustration,  the  most 
painful  place  of  the  eye  first  affected  is  situated  near 
the  upper  and  outer  edge  of  the  cornea,  perhaps  at  the 
spot  where  a  scleral  wound,  with  incarceration  of  a 
portion  of  the  iris,  has  occurred,  the  chief  or  even  ex- 
clusive seat  of  pain  in  the  second  eye  will  likewise  be 
located  at  a  precisely  corresponding  point  on  the 
supero-temporal  margin  of  the  cornea. 

In  the  present  relation  another  phenomenon  which 
has  been  observed  in  several  cases  of  sympathetic  cy- 
clitis  deserves  mention.  Schenkl  discovered  several 
silvery-white  eyelashes  on  the  temporal  half  of  the 
upper  left  eyelid  of  a  boy,  nine  years  of  age,  at  a 
time  when  this  eye  was  sympathetically  inflamed,  in 
consequence  of  an  injury  received  by  the  right  eye. 
On  the  upper  lid  of  the  right  eye  all  the  eyelashes 
were  perfectly  white,  with  the  exception  of  a  minute 
portion  of  their  extremities,  which  was  very  dark. 
Jacobi  also  noticed  in  an  eye,  sympathetically  affected 
with  irido-cyclitis,  that  the  lashes  of  the  nasal  half  of 
the  upper  lid  were  altered  in  color  to  snow-white, 
whilst  on  the  outer  half  of  the  same  lid  the  lashes  were- 
black  and  white  in  about  equal  proportions,  the  lower 
lid  presenting  merely  a  few  white  hairs. 


86  SYMPATHETIC   DISEASES   OF   THE   EYE. 

Have  we  now  exhausted  all  the  forms  of  sympathetic 
disease  that  may  invade  the  uveal  tract  f  It  would 
seem  not.  Let  us  first  notice  a  case  reported  by  Hor- 
ner  (1873).  In  an  eyeball  which  has  long  cpncealed 
a  foreign  body,  symptoms  of  irido-cyclitis  set  in.  In 
the  opposite,  heretofore  healthy,  but  somewhat  myopic 
eye,  a  rapidly  progressing  impairment  of  vision  takes 
place.  The  ophthalmoscope  reveals,  in  explanation  of 
the  latter  defect,  &  peculiar  form  of  patches  in  the  cho- 
roid,  chiefly  in  the  neighborhood  of  the  macula  lutea. 
Very  numerous,  minute,  yellowish  white,  imperfectly 
defined  specks,  are  seen  behind  the  retina.  The  dis- 
ease progresses  painlessly  and  without  signs  of  irrita- 
tion. The  spots  of  exudation,  in  the  choroid,  enlarge 
and  coalesce.  After  a  year  vision  has  become  so  much 
reduced  that  fingers  cannot  be  counted  at  a  greater 
distance  than  four  feet  with  the  central  portion  of  the 
retina,  and  seven  feet  with  excentric  vision.  The 
function  of  the  retina  suffers,  in  this  case,  in  conse- 
quence of  the  extension  of  the  choroidal  exudation  to 
the  layer  of  cones  at  the  yellow  spot.  There  was  no 
well-defined  primary  sympathetic  affection  of  the 
retina. 

Yignaux  (1877)  discovered,  with  the  ophthalmo- 
scope, a  commencing  atrophic  choroiditis  of  sympa- 
thetic origin,  which  was  the  cause  of  a  very  pronounced 
disturbance  of  vision. 

The  conjunction  of  choroiditis  with  retinitis  (cho- 


PATHOLOGY.  87 

roido-retinitis)  as  a  form  of  sympathetic  ophthalmia, 
was  described  by  v.  Graefein  1866  ;  although,  accord- 
ing to  the  statement  of  Laqueur,  a  sympathetic  neuro- 
retinitis  had  been  previously  noticed  by  Rheindorf 
(1864).  After  the  extraction  by  v.  Graefe  of  a  dislo- 
cated chalky  lens  from  the  anterior  chamber,  cyclitis 
ensues  in  the  same  eye.  Six  weeks  after  the  operation, 
the  sight  of  the  other  eye,  which  has  hitherto  been  per- 
fectly good,  begins  suddenly  to  be  impaired,  although 
no  pain  is  noticed.  JThe  ophthalmoscope  discloses  a 
delicate  and  diffuse  cloudiness  of  the  retina  all  around 
the  entrance  of  the  optic  nerve.  Soon  afterward, 
slight  symptoms  of  iritis  serosa  are  noticed,  in  the  form 
of  very  delicate  punctiform  opacities  in  the  membrane 
of  Descemet.  After  vision  has  sunk  to  one-eighth  of 
the  normal  amount,  and  the  disease  has  continued  at  its 
acme  for  several  weeks,  a  gradual  but  uninterrupted 
improvement  takes  place.  The  morbid  appearances 
visible  with  the  ophthalmoscope  recede  less  rapidly 
than  the  functional  disturbances.  Disseminated  patches 
of  exudation  are  conspicuous  on  the  choroid,  for  a  con- 
siderable time,  while  the  fine  punctiform  deposits  on 
the  posterior  surface  of  the  cornea  are  the  slowest  to 
disappear.  The  field  of  vision  is  complete  in  every 
direction,  and  vision  is  increased  to  four-fifths  nor- 
mal. 

In  the  secona  of  v.  Graefe's  cases,  a  patient,  twenty 
years  of  age,  blind  in  one  eye  since  childhood,  coin- 


80  SYMPATHETIC   DISEASES    OF   THE    EYE. 

plains  that  the  ruined  eye  has  been  painful  during  the 
last  few  months.  The  globe  of  the  best  eye  is  moder- 
ately sensitive  to  the  touch,  and  there  is  some  impair- 
ment of  vision.  A  slight  haziness  is  diffusedly  spread 
through  the  retina,  circumscribed  opacities  are  seen  in 
the  vitreous,  and  the  choroid  exhibits  trivial  alterations 
of  structure.  After  enucleation  of  the  blind  eye,  the 
sympathetic  manifestations  slowly  disappear  from  the 
other. 

Schweigger  (1875),  however,  aljudes  to  the  foregoing 
diagnoses  of  v.  Graefe  only  to  throw  doubt  upon  them, 
and  adds  that  it  requires  a  number  of  analogous  cases 
to  supply  satisfactory  evidence  of  the  correctness  of 
such  a  diagnosis  (sympathetic  retinitis).  For  that 
reason  we  must  here  notice  similar  cases. 

Pooley  (1871)  reports  two  cases  of  sympathetic  oph- 
thalmia, distinguished  by  the  occurrence  of  nenro- 
retinitis.  In  both  of  them  the  injured  eye  was  still 
abnormally  sensitive ;  whilst  iritis,  and  molecular 
opacities  in  the  vitreous,  were  conjoined  with  the 
retinal  affection,  in  each  case.  Galezowski  (1871)  di- 
agnosticates sympathetic  retinitis,  characterized  by 
whitish  exudations  and  hsemorrhagic  extravasations 
into  the  retina,  followed  by  recovery,  but  with  perma- 
nent obliteration  of  some  of  the  implicated  vessels. 
He  supports  his  diagnosis  by  a  similar  case  of  Pol- 
bean's,  which  he  observed  with  the  latter.  Gosseliii 
(1872)  speaks  of  a  case  of  sympathetic  inflammation 


PATHOLOGY.  89 

of  the  retina  and  choroid,  marked  by  pigment  spots, 
ecchymoses,  and  inflammatory  exudations,  together 
with  a  small  posterior  adhesion.  The  vision  of  the 
sympathizing  eye  became  suddenly  impaired,  at  a  time 
when  the  stump,  to  which  the  opposite  injured  eyeball 
had  become  reduced,  was  the  seat  of  an  unusual  ex- 
acerbation of  pain.  H.  Miiller  (1873)  relates  that 
Jacobson  saw  a  sympathetic  choroido-retinitis  localized 
in  the  neighborhood  of  the  entrance  of  the  optic  nerve, 
the  other  eyeball  being  at  the  time  in  a  state  of 
painful  atrophy,  ensuing  upon  cyclitis  produced  by  a 
cataract  operation.  Hirschberg  (1874)  recognizes  a 
sympathetic  retinitis,  characterized  by  great  hyperse- 
mia  of  the  retinal  veins,  together  with  slight  diffuse 
cloudiness  of  the  retinal  structures,  at  a  period  when 
the  opposite  phthisical  eye  was  still  very  painful  to  the 
touch  over  the  ciliary  region.  Pfliiger  (1875)  meets 
with  sympathetic  symptoms  in  the  form  of  inflamma- 
tion of  the  intra-ocular  extremity  of  the  optic  nerve 
and  the  circumjacent  portion  of  the  retina.  We  have 
already  mentioned  this  case,  in  which  it  was  found, 
upon  dissection,  that  an  inflammatory  infiltration  of 
the  iris,  unaccompanied  with  cyclitis,  was  the  lesion 
affecting  the  primarily  diseased  eye.  Among  the 
ninety  cases  adduced  by  Eossander  (1876),  sympathetic 
choroido-retinitis  figures  three  times,  although  one  of 
these  cases  holds  its  position  with  doubtful  propriety, 
according  to  the  opinion  of  Eossander  himself.  In 


90  SYMPATHETIC   DISEASES    OF   THE   EYE. 

Leber's  work  (1877),  "  Ueber  die  Krankheiten  der 
Netzhaut  und  des  Sehrierven  "  (On  the  Diseases  of  the 
Retina  and  Optic  Nerve),  only  a  single  paragraph  is 
devoted  to  sympathetic  retinitis.  "  The  affection;"  says 
Leber,  "  is  usually  conjoined  with  serous  irido-cyclitis 
and  haziness  of  the  vitreous;  after  the  media  clear  up 
the  ophthalmoscopic  evidences  of  the  affection  are 
sometimes  unmistakable."  The  sympathetic  retinitis 
is  usually  characterized  by  a  diffuse  cloudiness  of  the 
structures  of  the  retina,  to  which  a  redness  of  the  disc 
of  the  optic  nerve  is  usually  superadded.  But,  accord- 
ing to  Leber,  the  retinitis  is  not  simply  associated  with 
irido-cyclitis,  but  is  dependent  upon  the  latter ;  for  he 
commences  by  saying  that  "sympathetic  irido-cyclitis 
also  leads,  now  and  then,  to  the  development  of  reti- 
nitis." Finally,  Vignaux  (18 77)  narrates  several  cases 
of  sympathetic  choroido-retinitis,  as  well  as  of  retinitis, 
without  iritis  or  irido-cyclitis.  In  some  of  the  latter 
cases  the  ophthalmoscopic  changes  are  described  so 
meagrely  as  to  throw  doubt  upon  the  positive  pres- 
ence of  either  choroiditis  or  retinitis,  and  the  sympa- 
thetic affection  in  these  cases  might  as  well,  or  better, 
be  accepted  as  amblyopia  without  underlying  struc- 
tural changes.  Nevertheless,  the  existence  of  retinitis, 
as  an  expression  of  sympathetic  disease  of  the  eye,  can 
no  longer  be  regarded  as  an  open  question.  This  kind 
of  retinitis  is  very  generally  characterized  by  diffuse 
cloudiness  of  the  retina ;  but  whether  the  sympathetic 


PATHOLOGY.  91 

nature  of  such  forms  of  retinitis  as  Galezowski  and 
Gosselin  describe,  is  to  be  established  rather  by  the 
presence  of  other  and  deeper  changes  in  the  retina, 
cannot 'to-day  be  decisively  settled. 

We  should  here  notice  a  certainly  very  important 
point  in  connection  with  sympathetic  retinitis.  Schna- 
bel  (1876)  has  stated  (and  Leber  has  likewise  expressed 
a  similar  opinion)  that  common  iritis  is  frequently 
complicated  with  diffuse  retinitis.  If,  therefore,  reti- 
nitis does  not  really  appear  as  an  independent  sympa- 
thetic affection,  but  is  only  superinduced  upon  sympa- 
thetic iritis,  the  sympathetic  character  of  the  affection 
fails  as  absolutely  as  does  that  of  secondary  glaucoma, 
when  the  latter  malady  supervenes  upon  a  complete 
posterior  synechia  of  the  pupillary  margin  of  the  iris, 
resulting  from  sympathetic  iritis.  Notwithstanding 
the  occurrence  of  this  complication,  however,  there  is 
no  doubt  that  retinitis,  without  iritis  and  cyclitis,  may 
arise  in  a  wholly  independent  manner,  from  sympathy 
with  the  offending  eye.  I  go  even  farther,  and  say : 
the  frequent  presence  of  irido-cyclitis,  interfering  with 

%. 

the  employ  men  t- of  the  ophthalmoscope,  prevents  the 
clinical  establishment  of  the  fact  that  retinitis  is  a 
very  common  manifestation  of  sympathetic  disease ; 
or,  in  other  words,  that  many  more  cases  of  retinitis 
are  sympathetic  than  those  in  which  clear  and  unmis- 
takable evidence  of  the  fact  can  be  obtained.  The 
last  suggestion  is  of  importance  in  connection  with 


r 


92  SYMPATHETIC    DISEASES   OF   THE   EYE. 

the  pathogeny  of  the  sympathetic  diseases,  and  \ve 
shall  have  occasion  to  resume  it  farther  on. 

We  leave  the  sympathetic  diseases  of  the  retina  with 
the  remark  that  the  case  of  typical  pigment-degenera- 
tion of  the  retina  (retinitis  pigmentosa\  described  by 
Robertson  (1871)  as  a  sympathetic  affection,  was  mani- 
festly connected  (Leber)  with  a  binocular  disease, 
which  existed  previously  to  the  injury  to  which  the 
supposed  sympathetic  disease  was  attributed. 

We  now  pass  into  an  uncommonly  dark  province, 
viz.,  that  of  the  sympathetic  affections  of  the  optic 
nerve.  Sympathetic  retinitis  may,  as  we  will  here  at 
once  state,  be  propagated  to  the  second  eye  along  the 
path  of  the  optic  nerve  ;  but  is  the  same  statement  ap- 
plicable to  the  other  diseases  of  the  optic-nerve  tract  ? 
Dransart  has  added,  much  to  the  description  of  this 
subject :  but  we  shall  only  mention  his  assertion  that 
simple  atrophy  of  the  optic  nerve  is  to  be  ranked  as 
one  of  the  sympathetic  affections.  But  he  certainly 
weakens  his  statement  very  much  when  he  includes 
"atrophy  of  the  choroid,  posterior  synechise,  and 
cataracts"  among  the  "frequent  accompaniments"  of 
sympathetic  atrophy  of  the  optic  nerve.  Mooreii  saw 
a  case  in  which  atrophy  of  the  optic  nerve  of  one  eye, 
caused  by  a  contusion,  was  followed  by  atrophy  of  the 
optic  nerve  of  the  opposite  eye.  This  last  case  is  clearly 
entitled  to  be  called  an  example  of  sympathetic  dis- 
ease, in  so  far  as  every  affection  is  to  be  regarded  as 


PATHOLOGY.  93 

sympathetic,  the  reproduction  of  which  in  the  second 
eye  is  ascribable  only  to  a  pre-existent  disease  in  the 
first  eye.  The  question,  however,  of  practical  signifi- 
cance is :  "Whether  we  can  have  simple  sympathetic 
atrophy  of  the  optic  nerve  in  the  second  eye,  under  the 
same  circumstances  in  which  other  sympathetic  affec- 
tions generally  become  developed  ?  I  would  not  like 
to  deny  off-hand  the  possibility  of  the  occurrence  of 
such  a  phenomenon.  Indeed,  from  my  personal  ob- 
servation of  two  somewhat  enigmatical  cases,  I  cannot 
wholly  avoid  the  belief  that  we  may  occasionally  dis- 
cover the  ophthalrnoscopical  picture  of  simple  atrophy 
of  the  optic  nerve,  which  is  directly  of  sympathetic 
origin. 

We  have  already  alluded  to  the  danger  of  implica- 
tion of  the  second  eye  which  now  and  then  attends  the 
enucleation  of  the  first  eye,  when  performed  for  prophy- 
lactic purposes,  and  it  is  now  our  purpose  to  describe 
the  sympathetic  phenomena  which  are  sometimes 
seen  in  the  second  eye  after  the  surgical  removal  of  its 
mate.  Colsmann  (1877)  removed  an  eyeball  which  had 
atrophied  in  consequence  of  an  injury,  and  was  omi- 
nously painful. .  A  few  days  after  the  operation,  the 
acuteness  of  vision  in  the  remaining  eye  sank  to  one- 
seventh  of  the  normal  amount.  Three  days  later  the 
ophthalmoscope  revealed  distinct  cloudiness  of  the  op- 
tic disc  and  of  adjacent  parts  of  the  retina,  the  cloudi- 
ness being  especially  conspicuous  in  the  vicinity  of  the 


94  SYMPATHETIC   DISEASES   OF   THE   EYE. 

yellow  spot.  The  field  of  vision  was  at  the  same  time 
concentrically  contracted.  Under  appropriate  treat- 
ment pursued  for  six  months,  vision  became  normal 
and  the  visual  field  complete  in  every  direction.  Cols- 
maun  also  reported  a  second  case  of  the  sort,  from 
Mooren's  clinic.  A  few  months  after  the  prophylac- 
tic removal  of  an  injured  eyeball,  the  patient  com- 
plained of  subjective  flashes  of  light  in  the  remaining 
eye,  but  vision  was  still  normal.  Six  months  later, 
the  acuteness  of  vision  was  exceedingly  diminished, 
the  patient  only  being  able  to  read  print  the  size  of 
No.  19  of  Jaeger's  test-types  (one  and  one-half  to  two 
centimetres  in  height).  Inflammation  of  the  optic 
disc,  with  very  extensive  cloudiness  of  the  retina,  was 
discovered  with  the  ophthalmoscope.  The  final  result 
of  this  case  is  not  known.  Colsmann  states  that  Hugo 
Miiller  had,  at  an  earlier  date  (1873),  described  a  case 
in  which,  five  days  after  the  removal  of  a  degenerated 
and  enlarged  eyeball,  the  patient,  without  previous 
symptoms  of  sympathetic  disease,  began  to  complain 
of  the  periodical  envelopment  of  the  whole  field  of 
vision  with  a  shining  white  cloud,  accompanied  by 
subjective  sensations  of  light.  In  .the  intervals  of 
these  attacks,  no  impairment  of  vision  could  be  ascer- 
tained, but  the  retina  was  cloudy  in  the  neighborhood 
of  the  optic  papilla.  Later,  however,  without  change 
in  the  ophthalmoscopic  appearances,  the  power  of  vis- 
ion began  to  deteriorate  rapidly,  but  was  restored  after 


PATHOLOGY.  95 

a  course  of  treatment  consisting  of  local  abstractions 
of  blood  and  the  administration  of  mercury.  We  must 
not  forget  to  add  that,  several  months  afterward,  the 
patient  experienced  an  attack  of  cyclitis,  with  increase 
of  intraocular  pressure  (sympathetic  glaucoma  ?), 
which  was  successfully  treated  by  iridectomy. 

"We  are  here  led  to  seek  an  answer  to  an  important 
question :  fs  there  a  sympathetic  glaucoma  ?  The 
question  is  not  whether  a  sympathetically  diseased  eye 
can  lose  its  sight  while  laboring  under  the  character- 
istic symptoms  of  glaucoma  (the  glaucomatous  symp- 
toms being,  in  such  a  case,  simply  superadded  to  those 
of  the  sympathetic  disease),  but  it  is  whether  primary 
glaucoma  can  be  developed  in  the  second  eye,  solely 
from  sympathy  with  the  eye  first  diseased.  In  other 
words,  can  a  disease,  whose  symptoms,  briefly  expressed, 
are  persistently  increased  tension  of  the  eye,  pulsation 
of  the  central  vessels  of  the  retina,  and  an  affection  of 
the  optic  nerve  usually  characterized  by  excavation  of 
its  intra-ocular  extremity,  arise  directly  from  a  disease 
or  injury  of  the  other  eye,  and  continue,  with  or  with- 
out inflammatory  phenomena  which  have  their  seat  in 
different  parts  of  the  eyeball,  until  the  sight  of  the 
affected  organ  is  destroyed  ? 

Still  another  limitation  must  be  made.  It  some- 
times happens,  after  the  operation  of  iridectomy  has 
been  performed  for  the  relief  of  glaucoma  of  the  one 
eye,  that  the  other,  hitherto  perfectly  healthy  eye,  is 


96  SYMPATHETIC   DISEASES   OF   THE   EYE. 

attacked  with  the  most  violent  symptoms  of  acute  glau- 
coma, so  that  the  patient,  upon  whom  the  operation 
on  the  first  eye  was,  perhaps,  undertaken  merely  for 
the  removal  of  pain,  and  with  no  hope  of  restoring  its 
lost  sight,  becomes  totally  blind.  The  question  whether, 
under  these  conditions,  the  outbreak  of  glaucoma  in 
the  second  eye  is  of  sympathetic  origin,  and  ensues 
upon  the  operative  injury  inflicted  on  the  first  eye,  in 
the  same  mode  in  which  sympathetic  disease  may  pro- 
ceed from  any  other  kind  of  traumatic  injury  of  the 
organ,  is  here  answered  in  the  negative,  its  fuller  dis- 
cussion being  postponed  until  we  publish  our  work  on 
the  theory  of  glaucoma. 

Let  us  reduce  our  statement  and  inquiry  to  the  fol- 
lowing terms :  An  eye  is  destroyed  by  irido-cyclitis, 
and  the  opposite  eye  becomes,  in  consequence  of  the  first 
lesion,  affected  with  sympathetic  serous  iritis.  Every 
serous  iritis,  of  whatever  origin,  may  possibly  cause 
secondary  glaucoma.  I  have  never  personally  seen  this 
effect  produced  by  sympathetic  serous  iritis  ;  but,  even 
admitting  its  occurrence,  the  fact  is  beside  our  ques- 
tion. Then,  again,  instead  of  serous  iritis,  the  sympa- 
thy may  manifest  itself  in  the  shape  of  plastic  iritis, 
which  may  excite  secondary  glaucoma  by  the  round- 
about way  of  exclusion  of  the  pupil.  We  cannot  deny 
that  this  complication  really  may  occur  in  the  sympa- 
thetic eye,  but  the  admission  does  not  answer  our  ques- 
tion, which  is:  Can  primary  glaucoma  be  sympatheti- 


PATHOLOGY.  97 

cally  produced  in  the  second  eye  by  an  irido-cyclitis, 
or  an  irido-cyclo-choroiditis  of  the  first  eye? 

Sympathetic  glaucoma  appears  to  have  been  first 
described  by  v.  Graefe  (1857).  After  narrating  a  par- 
ticular case,  he  superadds  the  remark  that  he  has  "  re- 
peatedly met  with  a  similar  condition  of  things,  viz. : 
absolute  arnaurosis  of  one  eye,  due  to  the  destructive 
effects  of  choroiditis  ;  and  amblyopia  of  the  other  eye, 
without  any  signs  of  irritation  whatever,  although  the 
affection  was  accompanied  with  progressive  limitation 
of  the  field  of  vision,  as  well  as^  Excavation  of  the 
optic  nerve,  visible  with  the  ophthalmoscope."  V. 
Graefe  thought  it  possible  that  "  disturbance  in  the  cir- 
culation and  secretion  of  the  choroid  might  cause  in- 
creased intra-ocular  pressure  and  consequent  cupping 
of  the  optic  nerve  entrance  ; "  in  other  words,  a  true 
sympathetic  glaucoma.  Many  other  published  accounts 
of  sympathetic  glaucoma  are  extant  (Homer,  Mooren, 
Coccius,  Carter,  II.  Muller,  Pomeroy,  Rossander,  "Vig- 
naux);  and  divers  authors  who  have,  perhaps,  no  per- 
sonal knowledge  of  sympathetic  glaucoma,  accept  it 
on  the  ground  of  v.  Graefe's  early  observations.  Nev- 
ertheless, this  form  of  sympathetic  ophthalmia  falls 
somewhat  short  of  general  recognition.  Maats  (1805) 
refuses  to  concede  it,  and  JBrecht  (1874)  expresses  his 
opinion  that  in  v.  Graefe's  cases  the  supposed  affection 
was  mistaken  for  sympathetic  amblyopia  with  limita- 
tion of  the  field  of  vision,  without  alterations  of  strnc- 
5 


98  SYMPATHETIC   DISEASES    OF   THE   EYE. 

ture.  But  the  most  powerful  antagonist  of  v.  (rraefe's 
observations  is  v.  Graefe  himself.  For  in  1866,  in 
connection  with  his  first  description  of  sympathetic 
choroido-retinitis,  he  emphasizes  only  two  forms  of 
sympathetic  inflammation,  viz.,  iritis  maligna  and  iritis 
serosa,  and  positively  asserts  that  sympathetic  irido- 
cyclitis  "  never,  or  only  in  the  rarest  exceptional  cases, 
shows  any  tendency  to  produce  an  increase  of  the 
intraocular  pressure,  or  an  excavation  of  the  optic 
nerve." 

It  now  seems  doubtful  whether  typical  simple  glau- 
coma without  inflammatory  symptoms,  can  be  uncon- 
ditionally admitted  into  the  group  of  sympathetic 
affections,  especially  since  v.  Graefe  himself  abandoned 
this  theory,  which  he  at  first  constructed  upon  the  basis 
of  a  few  cases  which  seemed  to  support  it.  I  would 
further  suggest  that  there  is  a  manifest  inconsistency 
in  acknowledging  the  existence  of  this  kind  of  sym- 
pathetic glaucoma,  so  long  as  it  continues  to  be  regarded 
as  a  secondary  glaucoma  following  serous  cyclitis. 
For  the  presence  of  serous  cyclitis  would,  under  the 
latter  restriction,  only  be  revealed  by  the  glaucomatous 
symptoms;  and  in  case  the  glaucoma  were  viewed 
simply  as  a  product  of  serous  cyclitis,  the  very  nature 
of  a  primary  sympathetic  glaucoma  would  be  preju- 
diced. Primary  glaucoma  simplex  would  then  be 
nothing  else  than  a  serous  cyclitis ;  but  to  designate 
as  a  primary  sympathetic  glaucoma,  a  secondary  glau- 


PATHOLOOY.  99 

coma  resulting  from  serous  cyclitis,  would  be  quite 
inadmissible. 

The  existence,  as  a  sympathetic  affection,  of  acute 
glaucoma,  i.e.,  primary  glaucoma  with  all  its  peculiar 
inflammatory  phenomena  (which  we  shall  not  stop  to 
describe  in  this  place),  must  be  regarded  as  extremely 
problematical,  and  as  not  hitherto  satisfactorily  dem- 
onstrated. Even  the  case  reported  by  Jany  (1877), 
who  saw  the  right  eye  affected  by  what  he  supposed 
to  be  sympathetic  acute  glaucoma,  during  an  attack 
of  scleritis  and  iritis  of  the  left  eye,  is  lacking  in. 
some  of  the  indispensable  characteristics  of  a  sym- 
pathetic disease.  But.  the  case  is  quite  different, 
where  increase  of  tension  is  superadded  to  those  in- 
flammatory symptoms  which  are  diagnostic  of  irido- 
cyclitis.  Even  where  increase  of  intraocular  pressure 
is  noticed  in  connection  with  ciliary  injection,  sensi- 
tiveness of  the  ciliary  body  to  the  touch,  adhesions  be- 
tween the  iris  and  anterior  capsule,  and  opacities  of  the 
vitreous,  glaucoma  is  not  necessarily  present,  and  cer- 
tainly not  a  sympathetic  glaucoma.  Augmented  in- 
traocular pressure  may  Represent  during  every  acute 
inflammation  of  the  eye,  of  whatever  kind  or  origin. 
But  if  the  increased  intraocular  pressure,  under  the  in- 
fluence of  which  vision  is  sooner  or  later  destroyed, 
is  not  permanent,  although  it  may  be  variable,  the 
disease  is  not  glaucoma.  The  heightened  intraocular 
pressure,  which  may  be  present  at  one  stage  in  irido- 


100  SYMPATHETIC    DISEASES   OF   THE   EYE. 

cyclitis,  subsides  in  the  generality  of  cases ;  but  even 
if  this  were  not  the  case — if  the  eyeball  remained  ab- 
normally hard  until  vision  were  destroyed — the  case 
would  evidently  be  one  of  secondary  glaucoma,  en- 
suing on  irido-cyclitis.  The  inflammatory  symptoms 
of  irido-cyclitis  differ  so  widely  from  those  of  glau- 
coma, that  there  can  be  no  risk  of  mistaking  a  pri- 
mary glaucoma  for  an  irido-cyclitis.  It  is  the  irido- 
cyclitis,  and  not  the  secondary  glaucoma  developed 
from  it,  which  is  the  sympathetic  affection. 

A  very  peculiar  form  of  sympathetic  glaucoma, 
called  sympathetic  hcemorrhagic  glaucoma,  was  de- 
scribed by  H.  Pagenstecher  (1877).  Hsemorrhagic 
glaucoma  is  characterized  by  the  extravasation  of  blood 
into  the  retina,  accompanied  by  the  most  violent  symp- 
toms of  glaucoma,  so  that  -the  disease  has  sometimes 
been  called  a  secondary  glaucoma.  According  to  the 
description  given  of  Pagenstecher's  case,  however,  the 
glaucomatous  phenomena  were  first  noticed,  and  sub- 
sequently followed  by  the  retinal  effusions.  The  left 
eye,  from  which  the  sympathetic  affection  in  the 
opposite  eye  was  supposed  to  proceed,  showed  at  the 
time  when  its  partner  was  affected  nothing  more  than 
an  ulceration  of  the  cornea,  which  had  not  yet  caused 
perforation.  Later,  a  perforation  of  the  cornea  en- 
sued, and  led  to  phthisis  of  the  globe.  At  the  date 
of  the  enucleation  of  the  left  phthisical  and  blind 
eye,  its  tension  was  augmented  ;  it  was  only  moder- 


PATHOLOGY.  101 

ately  sensitive  to  heavy  pressure  (consequently  less 
sensitive  than  a  healthy  eyeball),  and  the  cornea, 
which  was  flattened,  and  mostly  converted  into  cicatri- 
cial  tissue,  was  extremely  anaesthetic.  The  same  an- 
aesthetic condition  was  noticed  in  the  conjunctiva. 
The  operation  was  followed  by  a  decided  improve- 
ment in  the  condition  of  the  right  eye,  which,  however, 
again  became  worse  several  weeks  after  the  enucleation, 
during  the  course  of  a  lobular  pneumonia.  It  again 
improved ;  but,  in  consequence  of  the  passing  of  the 
patient  from  observation,  the  case  was  not  followed  to 
its  conclusion.  Can  any  positive  causal  connection 
between  the  diseases  of  the  two  eyes  be  here  made 
out  ?  The  improvement  of  the  abnormal  tension  and 
impaired  vision,  which  followed  the  enucleation  is 
very  striking,  and  favors  this  view.  But  did  not  the 
rest  and  restricted  diet  (to  which  the  "  plethoric  sex- 
agenarian, who  was  not  averse  to  the  pleasures  of  the 
table,"  must  certainly  have  been  submitted,  for  a  time 
at  least,  after  the  operation)  have  an  influence  in  pro- 
ducing the  (possibly  only  transitory)  change  for  the 
better?  Certainly,  the  condition  of  the  primarily  dis- 
eased eye,  as  well  at  the  time  of  the  first  "  sympa- 
thetic "  glaucomatous  attack  of  the  right  eye,  as  at  the 
time  of  the  enucleation,  was  not  such  as  to  establish 
beyond  a  doubt  its  agency  in  exciting  the  disease  of 
the  second  eye. 

To  fill  the  complete  catalogue  of  sympathetic  dis- 


102  SYMPATHETIC   DISEASES    OF   THE   EYE. 

eases,  we  will  further  mention  that  Schmidt  /(1874:) 
discovered  a  few  opacities  pervading  the  vitreous,  in 
the  form  of  grayish-black  filaments,  which  he  ascribed 
to  a  sympathetic  source.  There  was  no  trace  of  ac- 
companying iritis,  nor  of  other  inflammatory  processes 
in  the  nveal  tract. 

Finally,  Briere  (1875)  reports  a  case  of  sympathetic 
cataract.  The  opinion  expressed  by  Briere,  however, 
that  the  cataract  described  by  him  should  be  grouped 
among  the  sympathetic  affections,  is  arbitrary.  A 
well-authenticated  case  of  sympathetic  cataract  re- 
mains for  future  discovery.* 

The  severest  forms  of  sympathetic  disease  are  in- 
flammations of  the  iris,  the  ciliary  body,  and  the 
choroid,  on  the  one  hand,  and  those  of  the  optic  nerve 
and  the  retina  on  the  other.  The  serious  lesions  of 
the  latter  structures  are  usually  concealed  by  the  in- 
flammatory processes  that  simultaneously  occur  in  the 
uveal  tract.  Among  the  sympathetic  affections  of  the 
nveal  tract,  iritis  serosa  constitutes  a  remarkable  ex- 
ception to  their  generally  dangerous  character.  It 
sounds  paradoxical,  bnt  it  is  nevertheless  true,  that  the 
existence  of  sympathetic  serous  iritis  need  excite  less 
anxiety  than  that  of  sympathetic  irritation,  for  the 

*  Kriickow  (1880)  has,  however,  described  two  cases,  in  which 
the  sympathetic  cataract  revealed  itself,  in  each  instance,  in  the 
form  of  an  opacity,  confined  exclusively  to  the  anterior  capsule  of 
the  lens. — TRS. 


PATHOLOGY.  103 

latter  affection  frequently  sets  on  foot  the  worst  forms 
of  sympathetic  ophthalmia,  proceeding  to  the  destruc- 
tion of  the  eye  ;  while  genuine  simple  iritis  serosa 
possesses  very  little  inherent  tendency  to  destructive 
results. 

Sympathetic  ophthalmia  is  especially  prone  to  be 
caused  by  injuries  of  the  eye,  because  those  morbid 
processes  which  constitute  it  are  much  more  fre- 
quently of  traumatic  than  of  spontaneous  origin. 
Modern  ophthalmology,  instead  of  diminishing  the 
sources  of  sympathetic  disease,  has  increased  them. 
The  linear  method  of  extracting  cataracts  is  one  of 
these  sources ;  although,  happily,  when  we  place  in  the 
balance  the  advantages  and  the  evils  of  this  operation, 
the  former  outweigh  the  latter.  The  operation  of  irido- 
desis  is  less  fortunate,  and  raises  doubts.  The  more 
recent  operative  procedure  of  drainage  of  the  eye 
awakens  still  graver  doubts  concerning  the  propriety 
of  its  employment.  Drainage  of  the  eye  consists  of  the 
insertion  and  retention  of  a  gold  wire  through  the  tunics 
of  the  eyeball,  with  a  view  to  causing  a  continuous  es- 
cape of  the  fluid  contents  of  the  globe  along  the  canal 
occupied  by  the  wire.  It  was  the  hope  of  the  advo- 
cates of  this  method  of  treatment  that  it  would,  on  the 
one  hand,  prevent  the  re-accumulation  of  subretinal 
fluid,  in  cases  of  detachment  of  the  retina,  and  on  the 
other,  keep  within  normal  limits  the  intraocular  pres- 
sure in  glaucoma,  and  thereby  become  an  effective 


104  SYMPATHETIC   DISEASES   OF   THE   EYE. 

therapeutical  agent  in  both  these  affections.  But  the 
injury  to  the  eyeball  incident  to  this  operation  will 
seldom  be  tolerated,  and  notwithstanding  the  transi- 
tory relief  obtained,  an  insidious  inflammation  of  the 
nveal  tract  will  be  set  up  in  the  great  majority  of 
cases,  with  imminent  danger  of  sympathetic  disease. 
I  have,  in  fact,  learned  without  surprise,  that  where 
eyeballs  have  been  drained  by  this  process,  it  has  often 
become  necessary  to  enucleate  them,  on  account  of 
the  sympathetic  affections  which  they  have  induced. 


SECTION    IV. 


PATHOGENY. 

WE  will  first  make  -a  few  general  remarks  on  the 
pathogeny  of  the  subject  under  discussion.  The  fact 
that  a  disease  of  any  part  of  the  body  should  be  the 
cause  of  disease  in  a  symmetrical  member  must  in  any 
event  seem  something  extraordinary.  Human  pathol- 
ogy up  to  this  day  has  revealed  but  few  phenomena 
of  this  nature.  N  orris,  however,  in  his  paper  on  sympa- 
thetic affections  of  the  eye,  speaks  of  a  few  analogous 
occurrences  in  other  regions ;  for  example,  one  case 
by  Mitchell,  Morehouse,  and  Keen,  in  which,  after  a 
gunshot  wound  on  the  outer  side  of  the  thigh,  com- 
plete anaesthesia  was  noticed  on  the  corresponding 
side  of  the  other  thigh ;  and  another  by  Annandale,  in 
which,  after  a  wound  on  one  hand  had  healed  with  a 
painful  cicatrix,  a  similar  condition  developed  on 
the  other. 

Let  us  confine*  ourselves,  however,  to  the  eye,  and  at 
once  inquire  in  what  manner  inflammation  expends 
from  one  eye  to  the  other.  It  would  be  an  error  to 

answer  such  a  question  in  a  general  way.     Entering 
5* 


106  SYMPATHETIC  DISEASES  OF  THE  EYE. 

/ 

therefore  into  details,  we  soon  discover  that  the  expla- 
nation is  surrounded  with  difficulties  of  various  degree, 
depending  upon  the  locality  of  the  inflammation.  If 
we  assume  for  example  that  the  ophthalmoscope  re- 
veals an  inflammation  of  the  optic  nerve  and  retina 
in  the  sympathetically  affected  eye,  and  that  we  are 
justified  in  assuming  a  similar  inflammation  in  the  in- 
jured eye  (whose  deeper  structures  we  are  usually  un- 
able to  examine  on  account  of  entensive  alterations  in 
its  anterior  portion),  we  shall  have  no  need  of  pro- 
found theories  or  the  dragging  in  of  obscure  symptoms 
from  other  provinces  of  pathology,  in  order  to  under- 
stand what  is  going  on. 

In  case  pathological  anatomy  does/ not  plainly  in- 
form us  of  any  other  way,  we  can  assume  in  such  a 
case,  that  the  inflammatory  process  in  the  optic  nerve 
of  the  offending  eye  propagates  itself  centripetally 
(toward  the  brain);  the  moment  that  the  chiasma  is 
reached,  the  optic  nerve  of  the  second  eye  is  threatened. 
It  is  of  no  consequence  whatever,  in  so  far  as  concerns 
the  explanation  of  the  phenomenon,  whether  we  are  of 
those  who  claim  a  total,  or  of  those  who  claim  a  par- 
tial crossing  of  the  optic  nerves  at  the  chiasma ;  or 
whether  we  defend  the  view  that  all  the  fibres  from 
one  optic  tract  cross  over  at  the  chiasma  to  the  optic 
nerve  of  the  opposite  side,  or  that  &part  of  these  fibres 
remaining  on  the  same  side,  go  to  compose  the  optic 
nerve  of  the  same  side.  For,  in  every  case,  the  fibres 


PATHOGENY.  ]  07 

of  both  nerves  lie  so  close  together  at  the  chiasraa, 
that  it  would  be  miraculous  if  the  extension  of  an  in- 
flammatory process  (particularly  of  the  connective- 
tissue  elements)  were  to  confine  itself,  at  the  chiasma, 
to  the  fibres  of  one  optic  nerve,  and  carefully  avoid 
the  fibres  of  the  second  nerve  which  are  so  closely  in- 
terwoven with  those  of  the  former.  So  far  as  con- 
cerns our  present  considerations,  it  is  all  one  and  the 
same,  whether  the  process,  after  reaching  the  chiasma, 
advances  or  does  not  advance  still  further  into  the  cen- 
tre of  the  organ  of  vision,  along  the  corresponding  op- 
tic tract.  But  this  much  is  certain :  that,  so  soon  as  the 
fibres  of  the  second  optic  nerve  are  attacked  in  the 
chiasma,  the  inflammatory  process  may  extend  not 
only  toward  the  optic  tract,  but  also  toward  the  eye, 
and  finally  reach  the  terminal  expanse  of  the  optic 
nerve  in  the  retina. 

The  appearance  of  typical  irido-cyclitis  in  the  eye 
originally  affected,  accompanied  with  the  develop- 
ment of  optic  neuritis  in  the  second  eye,  does  not  in- 
terfere with  the  explanation  just  given,  for  in  such  a 
case  we  take  it  for  granted  that  neuritis  (or  neuro-re- 
tinitis)  is  simultaneously  associated  with  the  irido- 
cyclitis  in  the  first  eye.  But  how  can  we  explain  a 
sympathetic  inflammation  of  the  whole  choroidal  tract, 
and  above  all,  sympathetic  irido-cyclitis  plastica,  which 
many  oculists  consider  the  most  important,  if  not  the 
only  significant  symptom  of  the  sympathetic  affection  ? 


108  SYMPATHETIC   DISEASES    OF   THE   EYE. 

/ 

"We  might  imagine  that  under  such  circumstances,  also, 
the  inflammation  was  propagated  per  contiguum. 
Thus,  irido-cyclitis  may  always  be  the  primary  affec- 
tion in  the  eye  first  affected,  while  retinitis  may  be 
superadded  to  the  original  disease.  The  inflammatory 
process  would  then  be  simply  transmitted  along  the 
tract  of  the  optic  nerves  into  the  retina  of  the  second 
eye,  in  which  it  could  finally  extend  from  the  retina 
to  the  choroid.  It  is  so  common  to  see  the  choroid  in- 
vaded by  inflammation  from  the  retina,  that  were  a 
corresponding  view  permissible  in  the  case  of  sympa- 
thetic affection  of  the  uveal  tract,  all  obscurities  would 
be  removed  from  the  latter  disease,  and-  sympathetic 
inflammations  could  be  regarded  as  simply  transmitted 
continuously  and  per  contiyuum  from  the  irritating 
eye  through  the  chiasma. 

Although  the  affection  of  the  optic  nerve,  first  in 
the  one  eye,  and  subsequently  in  the  other,  is  still  too 
little  appreciated,  it  is  nevertheless  a  fact  that  sympa- 
thetic irido-cyclitis  does  not  originate  by  this  agency. 
For,  at  the  time  when  the  premonitory  symptoms  of 
this  latter  affection  appear,  the  retina  is  very  rarely,  if 
at  all  inflamed.  Otherwise,  why  should  not  the  most 
typical  symptoms  appear  in  the  choroid  proper,  which 
lies  throughout  in  immediate  and  extensive  contact 
with  the  retina  ?  In  point  of  fact,  it  is  the  most 
anterior  segment  of  the  uveal  tract  (the  ciliary  body 
and  the  iris)  which  first  suffers ;  that  very  portion 


• 

PATHOGEUY.  -jf.     109 

which  is  covered  by  a  merely  theoretical  part  of  the 
retina,  the  so-called  pars  ciliaris  retinae.  As  it  thus 
appears  that  inflammation  cannot  be  transmitted  to 
the  chorokl  of  the  opposite  eye  by  the  intermediation 
of  the  optic  nerve  and  retina,  we  must  either  seek 
another  path  of  communication,  or  else  assume  some 
remote  and  mysterious  action. 

.There  is,  however,  one  possible  path  of  direct  coin- 
man  ication  between  the  two  eyes.  I  refer  to  the  vas- 
cular circle  of  Willis,  lying  in  the  region  of  the 
chiasma,  at  the  base  of  the  brain,  corresponding  to  the 
sella  turcica,  and  embracing  the  chiasma  as  well  as 
the  tuber  cinereum  and  corpora  mamillaria.  Altera- 
tions in  the  choroidal  vessels  of  one  eye  might  be 
transmitted  to  the  chief  arterial  trunk  (the  ophthalmic 
artery) ;  from  there  into  the  internal  carotid,  and  so 
to  Willis's  circle :  thence  alonw  the  anterior  arch  of 

7  O 

this  circle  into  the  opposite  ophthalmic  artery,  and  so 
to  the  choroidal  region  of  the  second  eye. 

Cohnheim  has  already  shown  us  what  an  important 
role  is  played  in  inflammatory  processes,  by  alterations 
in  the  vascular  walls ;  indeed  in  his  opinion,  "  molec- 
ular alteration  of  the  vascular  walls,"  is  the  indis- 
pensable condition  for  inflammation.  The  only  pecu- 
liarity with  which  we  should  meet  in  considering 
such  a  theory  (even  if  all  necessary  assumptions  were 
fulfilled)  would  be  that  the  process  in  the  second  eye 
is  never  exhibited  throughout  the  entire  choroidal 


110  SYMPATHETIC   DISEASES   OF   THE   EYE.      , 

tract,  but  chiefly,  or  even  exclusively,  in  its  most  ante- 
rior segment.  Moreover,  in  the  present  state  of  our 
knowledge,  we  know  nothing  definite  of  any  such 
direct  transmission  of  inflammation  along  the  vessels. 
By  this,  however,  I  do  not  mean  to  assert  that  the 
question  of  the  participation  of  the  vessels  has  yet 
been  finally  settled. 

"We  have,  therefore,  nothing  else  to  do  than  to  keep 
to  the  nerves,  under  which  term  we  of  course  mean 
simply  the  ciliary  nerves.  The  short  ciliary  nerves 
contain  motor,  sensitive,  and  sympathetic  fibres ;  and 
we  shall  assume  that  every  short  ciliary  nerve  is  com- 
posed of  fibres  of  each  of  these  three  varieties.  The 
long  ciliary  nerves  which  arise  directly  from  the  naso- 
ciliaris  have  no  motor  fibres ;  of  their  sympathetic 
fibres  we  know  nothing.  Nevertheless,  Strieker's  ex- 
periments, which  prove  that  hyperseraia  is  caused 
whenever  we  irritate  the  sensitive  roots  of  the  spi- 
nal cord  (i.e.,  that  an  irritation  of  the  sensitive  roots 
excites  the  nerves  which  dilate  the  vascular  walls), 
would  seem  to  show  that  the  long  ciliary  nerves  are 
made  up  in  part  of  vascular  nerves,  which  conduct 
irritation  from  the  nerve-centre. 

We  are  not  inclined  to  acknowledge  that  the  real 
motor  nerves  of  the  internal  muscles  of  the  eye,  viz. : 
the  corresponding  fibres  of  the  third  pair,  which  sup- 
ply the  sphincter  iridis  and  the  ciliary  muscle,  as  well 
as  those  fibres  of  the  sympathetic  which  supply  the 


PATHOGENY.  Ill 

dilator  pupillse,  have  anything  to  do  with  the  transmis- 
sion of  sympathetic  inflammation.  There  remains, 
therefore,  for  consideration  only  the  sensitive  fibres  of 
the  trigeminus,  and  the  vascular  nerves  of  the  sympa- 
thetic. The  question  then  arises,  if  the  ciliary  nerves 
are  the  only  ones  which  act  as  conductors,  does  the 
capacity  for  transmission  belong  to  each  sort  of  fibres, 
or  only  to  one,  and  to  which  ?  So  far  as  concerns 
the  motor  nerves,  I  would  say  that  we  sometimes 
meet  with  simple  paresis  of  accommodation,  as  the 
only  symptom  of  sympathetic  irritation  (Pageustecher, 
Mooren,  Schiess-Gemuseus).  This  symptom,  how- 
ever, does  not  compel  us  to  accept  any  action  on  the 
part  of  the  motor  roots.  On  the  contrary,  it  can  be 
explained  in  a  very  simple  manner.  The  muscles  of 
accommodation  in  both  eyes  contract  synergically.  '  If 
the  contraction  of  one  ciliary  muscle  becomes  ex- 
tremely painful  on  account  of  some  morbid  affection 
.  which  has  attacked  it,  contraction  at  once  ceases,  and 
with  it  also  the  contraction  of  its  partner.  But  just  so 
soon  as  the  injured  eye  is  enucleated,  the  ciliary  mus- 
cle of  the  second  eye  at  once  resumes  its  function. 

If  it  is  the  sensitive  nerves  which  conduct  the  in- 
flammation, we  must  assume  that  either  some  indefina- 
ble irritation,  or  an  unknown  molecular  alteration,  or 
a  distinct  inflammatory  condition  passes  along  the 
fibres  into  the  brain,  and  reaches  the  central  nerve- 
cells  from  which  the  fibres  proceed  ;  that  this  morbid 


112  SYMPATHETIC   DISEASES   OF   THE   EYE. 

process  then  "springs  over"  (or  is  perhaps  transmitted 
by  fibres)  to  the  corresponding  nerve-cells  of  the  other 
side,  and  so,  in  turn  advancing  from  the  brain,  reaches 
the  terminal  filaments  of  the  sensitive  nerves  in  the 
second  eye.  If  the  sympathetic  fibres  act  as  conduc- 
tors, then  the  irritation  must  cross  over  to  the  other 
side,  in  the  vaso-motor  centre,  i.e.,  in  the  medulla  ob- 
longata,  or,  if  we  give  any  credence  to  Strieker's  ex- 
periments, beneath  the  medulla  oblongata. 

It  is  relatively  easy  to  assume  some  such  state  of 
things,  for  we  thus  safely  avoid  the  dangers  of  "  re- 
flex" action.  But,  admitting  that  all  this  is  proved, 
many  difficulties  still  confront  us,  in  o\ir  endeavor  to 
explain  the  origin  of  inflammation  in  the  sympatheti- 
cally affected  eye.  The  development  of  inflammation 
presupposes  the  fact  that  the  irritation  or  inflamma- 
tion of  sensitive  nerves  can  produce  the  most  violent 
inflammation  in  the  tissues  to  which  they  are  distrib- 
uted ;  or,  relatively,  that  irritation  of  the  sympathetic 
fibres  which  dilate  the  vessels,  or  paresis  of  the  fibres 
which  contract  the  vessels,  not  only  causes  an  enlarge- 
ment of  the  vessels  (hypersemia),  but  even  true  inflam- 
mation. 

General  pathology  now  busies  itself  but  little  with 
the  influence  which  the  nerves  may  exert  upon  inflam- 
mation, or  denies  it  entirely.  It  is  well  worth  observ- 
ing that,  from  this  point  of  view,  so  little  attention,  or 
even  none  at  all,  has  been  paid  to  sympathetic  ophthal- 


PATHOGEN Y.  113 

inia.  Herpes  zoster — a  disease  in  which  inflammation  of 
the  8R  in  extends  along  the  filaments  of  sensitive  nerve- 
fibre? — is  the  only  well-known  example  of  the  possible 
connection  between  an  affection  of  the  nerves  and  in- 
flammation, especially  since  the  so-called  neuro-para- 
lytic  inflammations — pneumonia  after  division  of  the 
par  vagum,  and  keratitis  after  paralysis  of  the  trige- 
minns — have  been  banished  into  the  province  of  trau- 
matic inflammation.  And  even  as  regards  herpes 
zoster,  Cohnheim  thinks  that  we  ought  to  wait  for 
further  and  more  careful  anatomical  or  experimental 
investigations,  before  building  conclusions  of  so  great 
an  amplitude  upon  a  very  few  facts.  On  the  other 
hand,  no  one  has  ever  yet  observed  the  development 
of  a  genuine  inflammation  as  the  outcome  of  that 
hypenemia  which  depends  upon  division  of  the  sym- 
pathetic nerve. 

In  considering  sympathetic  cyclitis,  however,  we 
must  suppose  some  such  direct  influence  of  the  cili- 
ary nerves  in  the  production  of  inflammation.  In  a 
clinical  point  of  view,  we  have  cases  which  afford 
such  a  hypothesis.  In  1866  v.  Graefe  said :  "  It  may 
be  of  interest  to  note  the  fact  that  in  two  cases  of  in- 
jury, in  which  I  did  not  enucleate  the  wounded  eye 
because  it  still  retained  some  traces  of  vision,  I  was 
able,  at  the  outbreak  of  the  sympathetic  affection,  to 
prove  that  the  second  eye  showed  increased  sensitive- 
ness at  a  point,  symmetrically  to  which  a  similar  condi- 


114  SYMPATHETIC   DISEASES   OF   THE   EYE. 

/ 

tion  was  present  in  the  first  eye  during  the  whole 
period  of  observation."  Bowman  has  also  made  one 
observation  of  the  same  nature. 

Such  exact  symmetry  as  this  is  supposed  to  be  ex- 
tremely rare  in  ophthalmology,  and  even  authors  who 
have  had  at  their  command  a  large  amount  of  mate- 
rial for  the  study  of  sympathetic  ophthalmia,  cite  only 
the  three  cases  of  v.  Graefe  and  Bowman.  Despite 
this  fact,  I  am,  nevertheless,  firmly  convinced  that 
this  phenomenon  is  by  no  means  rare.  Still,  it  is 
always  remarkably  striking,  no  matter  how  often  it 
may  be  observed.  I  have  seen  it  in  genuine  iritis 
maligna,  as  well  as  in  severe  plastic  iritis,  in  which  the 
circumference  of  the  iris  had  become  bulged  forward. 
It  is  also  sometimes  noticed  in  that  sympathetic  irrita- 
tive condition  which  is  usually  regarded  as  ciliary 
neuralgia  (page  63).  If  we  carefully  touch  the  region 
of  the  ciliary  body  of  the  sympathetically  affected  eye 
in  these  cases,  we  succeed  in  finding  at  some  spot  a 
pressure-point  which  is  chiefly  or  exclusively  sensitive 
ox  painful  to  the  touch.  If  we  then  test  the  eye  first 
affected,  we  are  almost  always  sure  to  find  an  exactly 
corresponding  spot  over  the  ciliary  region,  which  is 
chiefly  or  exclusively  sensitive  or  painful.  Although 
the  originally  affected  eye  frequently  possesses  but  one 
painful  spot,  while  the  rest  of  the  ciliary  body  re- 
mains quite  insensible  to  the  touch,  or  even  to  gentle 
pressure,  so  that,  under  these  circumstances,  it  is  suf- 


PATHOGEJSTY.  115 

ficiently  easy  to  discover  the  pressure-point  in  the  eye 
first  affected,  we  think  it  best  to  suggest  that,  in  testing 
the  sensibility  of  the  ciliary  body,  we  should  begin  in 
the  eye  affected  secondarily.  For  the  eye  originally 
affected  is  sometimes  so  extremely  sensitive  to  pain, 
that  the  attempt  to  discover  if  there  be  any  especi- 
ally painful  spot  in  the  ciliary  region,  without  know- 
ing exactly  where  to  seeJc  for  it^  is  barbarous,  to  say 
nothing  of  the  fact  that  it  may  be  impossible  of  ac- 
complishment. But  the  circumscribed  pain  from  pres- 
sure, in  an  eye  affected  sympathetically,  is  not  precise]y 
the  same  sort  of  pain  as  that  which  is  produced  by 
pressure  in  an  inflamed  region  of  the  body.  It  is  much 
oftener  discovered,  on  the  contrary,  as  has  already 
been  suggested,  even  where  we  have  nothing  but  a 
neuralgia  of  the  corresponding  ciliary  nerves — a  neu- 
ralgia which  may  disappear  without  passing  into  a 
state  of  inflammation. 

"If  we  reflect  upon  these  facts,  we  can  hardly  do  any- 
thing else  than  assume  that  the  inflammatory  irritation 
passes  from  the  ciliary  nerves  of  the  one  side  to  the 
corresponding  ciliary  nerves  of  the  other,  so  that, 
finally,  inflammation  can  be  excited  in  the  tissues  to 
which  these  nerves  are  distributed.  At  present,  how- 
ever, in  these  cases,  it  is  absolutely  impossible  for  us 
to  tell  whether  the  inflammation  is  transmitted  by  the 
sensitive  nerves,  which  are  evidently  affected,  or  by  the 
sympathetic  fibres.  Herpes  zoster  seems  to  show  an 


116  SYMPATHETIC   DISEASES    OF   THE   EYE. 

active  participation  on  the  part  of  the  sensitive  fibres ; 
but  we  must  not  forget  that,  as  sympathetic  fibres  are 
undeniably  present  in  the  ciliary  nerves,  we  cannot, 
without  further  proof,  deny  the  presence  of  the  same 
sort  of  fibres  in  the  sensitive  nerve-trunks  generally, 
as  was  demonstrated  by  Strieker's  experiments,  pre- 
viously mentioned. 

Having  thus  given  a  hasty  and  general  glance  at 
the  subject,  let  us  now  see  how  the  theory  of  the 
pathogeny  of  sympathetic  inflammation  has  been  built 
up  in  the  course  of  time,  upon  the  foundation  of 
hypotheses,  supported  by  clinical  and  pathological 
observations. 

If  Mackenzie  was  not  the  first  oculist  to  recognize 
sympathetic  ophthalmia,  we  may  claim  for  him  that 
he  was  the  first  author  who  published  any  papers 
that  show  deep  insight  into  this  terrible  disease. 
As  early  as  1844  he  had  already  developed  various 
hypotheses  concerning  the  pathogeny  of  this  affection, 
which  contain  very  nearly  all  that  has  been  discov- 
ered in  this  province  in  the  last  forty  years;  while  his 
works  show  that  he  had  studied  this  obscure  branch 
of  ophthalmology  much  more  carefully  than  is  nowa- 
days generally  believed.  For,  in  looking  over  his 
writings,  we  see  at  once  that  he  had  already  consid- 
ered the  three  paths  along  which  sympathetic  inflam- 
mation may  possibly  be  transmitted:  Firstly,  through 
the  vessels,  by  means  of  their  anastomoses  within  the 


PATHOGENY.  117 

skull ;  secondly,  along  the  ciliary  nerves ;  and  thirdly, 
through  the  retina  and  optic  nerves.  Nor  do  we  now 
know  much  more  about  the  manner  of  transmission 
than  he  did,  for  he  says :  "  The  vessels  on  the  side  of 
the  injured  eye,  being  in  a  state  of  congestion  which 
may  increase  to  inflammation,  perhaps  communicate  a 
disposition  to  similar  disease  to  the  vessels  on  the 
opposite  side,  with  which  they  anastomose  inside  the 
cranial  cavity."  "The  ciliary  nerves  of  the  injured 
eye  might  be  the  paths  along  which  the  irritation  is 
conveyed,  through  the  mediation  of  the  third  and  fifth 
pairs,  to  the  brain,  from  which  it  is  reflected  along 
the  corresponding  nerves  of  the  opposite  side."  And 
finally,  speaking  of  the,  optic  nerves,  Mackenzie  says : 
"  It  is  extremely  probable  that  the  retina  of  the  in- 
jured  eye  is  in  a  state  of  inflammation  which  advances 
along  the  corresponding  optic  nerve  to  the  chiasma. 
From  there,  the  irritative  condition  to  which  the  in- 
flammation was  due  crosses  over  to  the  retina  of  the 
opposite  eye,  along  i'ts  corresponding  optic  nerve." 

Correct  as  this  last  view  must  appear,  even  in  our 
days,  Mackenzie  undoubtedly  erred  in  regarding  the 
"  union  of  the  optic  nerves  "  as  the  "  chief  medium  " 
by  which  sympathetic  inflammation  is  produced.  For, 
although  there  is  not  the  least  doubt  that  sympathetic 
neuro-retinitis  is  often  developed  in  the  manner  which 
Mackenzie  pointed  out,  sympathetic  inflammation  of 
the  uveal  tract,  as  we  have  already  seen,  cannot  be  ex- 


118  SYMPATHETIC   DISEASES   OF    THE   EYE.  / 

plained  by  the  extension  of  an  inflammation  of  the  re- 
tina to  the  region  concerned.  So  far  back  as  1849, 
Tavignot,  as  I  learn  from  Mooren,  regarded  sympa- 
thetic iritis  in  the  same  light  as  if  a  sympathetic  cili- 
ary neuralgia  were  the  primary  affection,  leading 
finally  to  hypersemia  and  inflammation.  Y.  Arlt 
also  showed,  at  a  later  date,  that  conduction  along  the 
ciliary  nerves  was  the  more  probable  path :  "We  can- 
not decide,  in  the  present  state  of  our  knowledge, 
whether,  in  such  cases,  the  optic  nerve  (the  neurilemma 
as  far  as  the  chiasma)  or  the  trigeminus  and  sympa- 
thetic ciliary  nerves  are  the  intermediate  agents,  al- 
though a  majority  of  facts  speak  in  favor  of  the  latter." 
Heinrich  Miiller  (1858)  was  tlje  first  to  awaken  the 
attention  of  the  ophthalmological  world  to  tho  role 
that  is  played  by  the  ciliary  nerves.  It  is  interesting 
also  to  note  the  fact  that,  from  this  time  onward,  the 
pathological  views  of  sympathetic  inflammation  under- 
went very  radical  changes,  although  Miiller's  views 
differ  so  slightly  from  those  held  by  Mackenzie. 
Miiller,  as  well  as  Mackenzie,  acknowledges  that  both 
the  ciliary  and  optic  nerves  participate  in  transmitting 
the  sympathetic  irritation,  but  the  former  expresses 
himself  in  such  a  way  that  it  seems  as  if  he  denied 
any  such  action  on  the  part  of  the  optic  nerve.  "Al- 
though I  will  grant  that  the  ciliary  nerves  may  often 
fan  the  fatal  sympathy  into  flame,  it  is  plain  enough,  at 
the  same  time,  that  I  do  not  deny  that  sympathy 


PATHOGENY.  119 

(which  assumes  so  many  mysterious  forms)  cannot  be 
transmitted  by  the  optic  nerve." 

Although  II.  Mtlller  followed  in  the  general  direc- 
tion which  had  been  indicated  by  his  predecessors, 
his  opinions  seemed  the  more  trustworthy  because 
they  were  for  the  first  time  based  on  anatomical  con- 
ditions. Among  others  of  this  sort,  Miiller  found  the 
ciliary  nerves  in  a  condition  of  partial  atrophy,  in  an 
eye  which  had  been  enucleated  on  account  of  the 
premonitory  symptoms  of  sympathetic  ophthalmia. 
But,  as  the  nerves  had  only  lost  their  medulla,  he 
thought  that  they  might  still  have  preserved  "  in  a 
greater  or  less  degree  "  their  capacity  for  transmitting 
irritations  toward  the  centre.  "  On  the  other  hand," 
continues  Miiller,  "  the  optic  nerve,  in  many  cases,  is 
in  such  a  condition  of  excessive  atrophy,  from  the 
retina  as  far  as  the  main  trunk,  that  it  could  hardly 
have  the  power  of  transmitting  an  irritation,  or  any 
other  process,  from  the  eye."  Nevertheless,  we  must 
emphasize  the  fact  that  Miiller  now  spoils  the  effect 
of  his  last  remark,  by  hastening  to  add  that  "  we  can 
hardly  say,  of  certain  fibres  in  the  region  of  the 
lamina  cribrosa,  whether  they  are  nervous  or  not." 
We  must  here  carefully  remark  that  Miiller  had  not 
discovered  any  anatomical  condition  by  which  the 
propagation  along  the  ciliary  nerves  could  in  any 
way  be  demonstrated ;  but  that  he  simply  based  his 
conclusion  upon  the  fact  that  the  ciliary  nerves  are 


120  SYMPATHETIC    DISEASES    OF   THE   EYE.    / 

less  liable   than   the  optic  nerves   to  degenerate  into 
complete  atrophy. 

As  years  passed  by,  the  opinion  that  sympathetic 
inflammation  was  transmitted  by  the  ciliary  nerves 
grew  more  and  more  fixed,  while,  during  the  same 
period,  the  theory  of  the  participation  of  the  optic 
nerves  in  the  sympathetic  process  fell  into  oblivion. 
Pagenstecher  (1862)  was  probably  the  first  observer  in 
Germany  who  wholly  opposed  the  participation  of  the 
optic  nerves,  and  referred  the  transmission  exclusively 
to  the  ciliary  nerves,  chiefly  to  their  "nutritive" 
sympathetic  fibres.  For  many  years  thereafter  the 
ciliary  nerves  were  regarded  as*  the  sole  conductors  of 
irritation  from  one  eye  to  the  other.  Nevertheless, 
a  few  men  (among  them  Mooren)  could  not  but  notice 
many  facts  that  tended  to  show  some  transmission 
along  the  optic  nerve.  In  these  exceptional  cases 
only  a  secondary  role  was  attributed  to  the  optic 
nerves.  Thus,  in  1869,  Mooren  says  that  every  sym- 
pathetic disturbance  depends  upon  an  irritation  of 
the  ciliary  nerves,  but  that  the  trigeminus  may  affect 
the  optic  nerves  in  the  following  manner :  the  irri- 
tation transmitted  from  the  trigeminus  to  the  optic 
nerve  of  the  eye  first  affected,  might  be  carried  along 
this  optic  nerve  to  the  second  eye ;  from  the  latter, 
in  turn,  it  might  extend  from  the  optic  nerve  to  the 
trigeminus,  "so  that  the  solution  of  transmitted  irrita- 
tive processes  takes  place  in  the  ciliary  ganglion."" 


PATIIOGENY.  121 

But,  beyond  this  obscure  reflex  action,  it  seemed  to 
Mooreu  that  a  third  factor  was  needed,  in  order  to 
explain  the  origin  of  sympathetic  affections  :  "  one 
which  fixes  the  relations  of  nutrition,  secretion,  and 
accommodation" — one  which  involves  a  co-operation 
of  the  sympathetic  nerve,  no  matter  whether  the 
transmission  is  effected  along  the  main  branches,  or 
directly  along  those  sympathetic  fibres  which  are  said 
to  accompany  the  optic  nerve. 

The  first  observer,  of  recent  date,  to  claim  that  the 
optic  nerve  plays  the  chief  role  in  the  transmission  of 
sympathetic  ophthalmia  is  Alt,  who  bases  his  opinion 
on  anatomical  discoveries,  which  show  a  large  per- 
centage of  alterations  in  the  retina  and  optic  nerve 
of  the  eye  originally  affected.  We  must  not  forget, 
however,  that  a  large  portion  of  these  changes,  such 
as  the  frequent  occurrence  of  detachment  of  the 
retina,  are  nothing  but  the  sequences  of  uveal  dis- 
eases. We  should  mention,  as  an  additional  point  of 
interest,  that  Alt  also  observed  three  cases  of  sym- 
pathetic neuro-retinitis.  Finally,  the  same  observer 
subscribes  to  the  extraordinary  opinion,  that  the 
whole  nervous  apparatus  shares  promiscuously  in  the 
transmission  of  sympathetic  irritation  to  the  second 
eye,  and  that  the  various  types  of  the  disease  in  ques- 
tion show  only  a  difference  of  degree. 

According  to  Mooren's  theory,  the  nerves  of  special 

sense  (that   is  to  say,  the   optic  nerves)  would  have 
6 


122  SYMPATHETIC   DISEASES   OF   THE   EYE.    ' 

to  be  additionally  endowed  with  the  capacity  for  con- 
ducting irritation.  But  if  we  assume  that,  at  the  time 
when  the  sympathetic  symptoms  appeared,  there  was 
no  nervous  connection  between  the  foreign  body  and 
the  optic  nerve,  and  that  it  would  lie  impossible  to 
prove  any  conduction  through  the  optic  nerve,  we 
should  have  to  rely  upon  a  different  sort  of  (reflex)  ac- 
tion between  the  ciliary  and  optic  nerves,  in  order  to 
explain  certain  sympathetic  disturbances  which  are  not 
of  an  inflammatory  character.  In  the  case  already 
cited  (page  67)  of  sympathetic  contraction  of  the 
field  of  vision  without  any  changes  recognizable  with 
the  ophthalmoscope,  JBrecht  expressed  his  opinion,  on 
anatomical  grounds,  that  the  optic  nerves  could  not  act 
as  conductors.  Nor  could  he  imagine  any  other  path 
for  the  transmission  of  sympathy  than  through  the 
ciliary  nerves.  Brecht  also  thought  it  quite  probable 
that  the  foreign  body  might  have  excited  inflammation 
in  some  of  the  ciliary  nerves,  which  have  the  property 
of  transmitting  irritation  toward  the  brain ;  that  this 
inflammation  extended  step  by  step,  and  finally  in- 
duced a  hyperaemic  condition  in  t"he  medulla  ob- 
longata,  with  myelitis  or  some  slight  inflammatory 
process  in  the  region  of  the  vaso-motor  centres.  Sub- 
sequently, this  inflammatory  process  caused  paresis  of 
the  vascular  walls,  and  hypersemia  of  the  retina  in  the 
second  eye,  which  was  the  one  at  fault  so  far  as  con- 
cerned the  disturbance  of  its  function.  Brecht  based 


PATHOGENY.  123 

his  argument  on  three  experimental  trials :  first, 
those  of  Lewison  on  frogs  (1869),  from  which  the 
experimenter  concluded  that  violent  irritation  of 
sensitive  nerves  paralyzes  the  reflex  activity  as  well 
as  those  voluntary  movements  which  are  dependent 
on  the  medulla  spinalis ;  secondly,  on  Leyden's  opin- 
ion (1865)  that  the  so-called  reflex  paralysis  (para- 
plegia, paralysis  of  the  sphincters),  which  is  often 
observed  after  chronic  affections  of  the  bladder  and 
other  tedious  diseases,  may  depend  upon  an  inflam- 
mation of  the  sensitive  nerves  of  the  organ  affected, 
which  duly  ascends  into  the  spinal  cord,  and  gives 
rise  to  a  myelitis ;  and  thirdly,  on  the  experimental 
studies  of  Feinberg  (1871),  who  observed  paralysis  of 
the  bladder  and  paraplegia  in  a  rabbit,  a  few  days 
after  cauterizing  the  ischiatic  nerve,  while  at  the 
post-mortem  examination  he  discovered  that  the  re- 
flex action  was  due  to  a  myelitis,  the  central  stump  of 
the  cauterized  ischiatic  nerve  being  quite  intact. 
This  goes  to  show  that  a  similar  inflammation  can 
gradually  extend  along  the  nerve.  Moreover,  it  is  to 
be  regarded  as  an  experimental  fact,  which  confirms 
Leyden's  discovery  in  man,  that  whenever  he  had  diag- 
nosticated, during  life,  a  neuritis  ascending  into  the 
spinal  cord,  he  always  found,  after  death,  a  cor- 
responding myelitis  at  the  place  where  the  nerves 
entered,  but  no  tokens  whatever  of  an  ascending 
neuritis. 


124  SYMPATHETIC   DISEASES   OF   THE   EYE. 

We  may  here  mention  still  another  possible  hy- 
pothesis. The  well-known  experiment  of  Golz,  in 
which  a  frog's  heart  ceases  to  beat  when  one  strikes 
a  few  rapid  blows  over  the  region  of  the  belly,  may 
be  interpreted  to  mean  that  the  centripetal  sympa- 
thetic nerves  of  the  viscera  conduct  a  reflex  irritation 
through  the- medulla  oblongata  to  the  vagus,  which  is 
the  retarding  nerve  of  the  heart.  Now,  in  the  same 
way,  we  might  agree  with  Brecht  in  supposing  that 
the  irritation  due  to  the  foreign  body  is  simply  trans- 
mitted, by  reflex  action,  along  the  sympathetic  fibres 
of  the  ciliary  nerves  which  lead  to  the  Ijrain  (are 
there  really  any  fibres  of  that  sort?}  through  the 
medulla  oblongata  to  the  ciliary  nerves  of  the  second 
eye,  which  lead  from  the  brain,  and  that  the  latter 
then  interfere  with  the  function  of  the  retina  itself, 
just  like  any  other  retarding  nerves.  Leber  also 
(1877)  is  of  the  opinion  that,  inasmuch  as  the  reflex 
paralysis  of  motor  nerves  has  been  abundantly  dem- 
onstrated, as  well  by  clinical  observations  as  by  expe- 
riments on  animals,  the  occurrence  of  a  reflex  paralysis 
u  of  sensitive  nerves,  especially  of  the  optic  nerve  or 
retina,"  cannot  at  present  be  denied  without  further 
argument. 

Those  observers  who  defend  reflex  neuroses  in  the 
province  of  sympathetic  affections,  imagine,  on  the  one 
hand,  that  the  inflammatory  irritation  is  undoubtedly 
conducted  along  the  optic  nerves,  but  that  in  the  eye 


PATHOGENY.  125 

affected  by  sympathy  the  irritation  crosses  from  the 
optic  nerve  to  the  ciliary7  nerves,  by  which  the  inflam- 
mation is  first  ushered  in.  Or,  on  the  other  hand,  they 
assume  that  the  sympathetic  symptoms  which  reveal 
themselves  on  the  part  of  the  retina  and  optic  nerve,  are 
not  produced  in  the  second  eye  by  direct  conduction 
of  the  irritation  from  one  optic  nerve  to  the  other,  but 
by  conduction  along  the  ciliary  nerves,  and  from  the 
latter  to  the  optic  nerve.  According  to  these  views, 
therefore,  the  whole  series  of  symptoms,  such  as  sensi- 
tiveness to  light,  rapid  weariness  of  the  eyes  during 
work,  rhythmical  indistinctness  of  the  field  of  vision, 
periodical  obscuration  of  vision,  dread  of  light,  sparks 
before  the  eyes,  degenerating  occasionally  into  exces- 
sive photophobia  and  photopsia,  anaesthesia  of  the 
retina  with  concentric  limitation  of  the  field  of  vision, 
and  finally  typical  retinitis  (the  latter  separated  from 
the  other  symptoms,  at  least  by  Leber,  and  regarded 
by  him  as  the  consequences  of  sympathetic  irido- 
choroiditis) — all  these  symptoms,  we  say,  are  to  be 
regarded  simply  as  a  series  of  reflex  neuroses,  the  pri- 
mary affection  having  its  seat  in  the  ciliary  nerves. 

The  foregoing  summary  shows  that  we  were  right  in 
designating  our  general  views  as  relatively  simple. 
But  we  will  now  go  farther,  and  examine  whether 
these  relatively  simple  views  will  not  satisfactorily  ex- 
plain all  the  phenomena  of  sympathetic  ophthalmia 
without  compelling  us  to  enter  upon  the  obscure  pro- 


126  SYMPATHETIC   DISEASES   OF   THE   EYE. 

vince  of  reflex  neuroses.  "When  Mackenzie  thought 
that  there  was  very  little  doubt  that  the  retina  of  the 
injured  eye  was  in  a  state  of  inflammation,  it  seems  as 
if  he  hit  the  mark  precisely.  Without  being  forced  to 
assume  some  mysterious  influence  on  the  part  of  the 
ciliary  nerves  upon,  the  optic  nerves,  it  has  now  been 
proved  that  the  injury  itself  is  capable  of  exciting  va- 
rious inflammatory  processes  in  the  interior  of  the  eye, 
and  that  they  may  (oftentimes,  perhaps,  from  some 
definite  lesion  of  the  parts  involved)  rapidly  attack  the 
optic  nerve.  In  this  point  of  view,  we  find  a  very  in- 
teresting fact  in  an  insignificant  remark  of  Brailey's, 
in  his  "  Pathological  Report  for  1876."  A  boy,  four 
years  old,  falls  with  a  knife  in  his  hand,  and  pierces 
the  lower  eyelid,  and  then  the  cornea,  as  well  as  a 
portion  of  the  sclerotica  right  and  left  from  the  cornea. 
Four  days  later  the  eye  is  enucleated.  The  retina 
and  choroid  are  both  in  situ.  The  entrance  of  the 
optic  nerve  is  swollen  and  completely  surrounded  by 
a  whitish  opacity,  near  which  lies  a  small  capillary 
hemorrhage.  The  microscopic  examination  leaves  no 
doubt  of  the  swelling  of  the  optic  nerve.  E.  Williams 
reported  at  the  International  Congress  in  New  York, 
in  1876,  two  recent  cases  in  his  own  practice,  in  which 
the  wounded  and  enucleated  eye  had  been  attacked,  in 
the  most  surprising  manner,  by  a  very  pronounced 
neuro-retinitis.  In  the  first  case  (in  which  enucleation 
was  performed  a  few  weeks  after  the  inj  ury),  Williams 


PATHOGENY.  127 

observed  the  most  extensive  swelling  of  the  optic  nerve 
that  he  ever  had  seen.  Hirschberg  also  expresses  as- 
tonishment over  a  similar  case  in  the  same  year.  In 
this  case  also,  as  in  the  one  reported  by  Brailey,  the 
eye  was  wounded  by  a  knife-blade,  although  eimclea- 
tiou  was  not  performed  until  nine  months  after  the  in- 
jury. The  optic  papilla  was  very  much  swollen,  and 
surrounded  by  a  well-developed  wall,  evidently  due  to 
hyperplasia  of  the  inner  granular  layer,  and  the  radi- 
ating fibres  of  the  retina.  Inasmuch  as  the  develop- 
ment of  the  neuro-retinitis  in  the  injured  eye  has  been 
demonstrated  by  Brailey,  at  an  early  date  after  an  in- 
jury, as  well  as  at  a  later  date  by  both  E.  Williams  and 
Hirschberg,  and  since  the, frequent  participation  of 
the  optic  nerve  in  the  inflammatory  process  in  the  in- 
jured eye  has  generally  been  confirmed  by  Alt,  we 
have  on  the  whole  to  take  it  for  granted  that  the  retina 
and  optic  nerve  in  the  eye  first  affected  are  either  ir- 
ritated or  inflamed  by  the  wound  itself,  or  by  the  mor- 
bid processes  which  follow  the  latter.  It  is,  of  course, 
hard  to  say  wherein  the  "  irritative  condition "  con- 
sists ;  but  it  is  a  fact  that  the  irritation  can  propagate 
itself  to  the  second  eye,  or  be  produced  in  the  second 
eye  by  inflammation  in  the  first  eye,  as  well  as  that 
the  irritation  can  disappear  after  the  removal  of  the 
original  source  of  disturbance  in  the  sympathetically 
affected  eye. 

Just  in  the  same  way  as  the  obscurations  of  the 


128  SYMPATHETIC   DISEASES    OF   THE   EYE. 

field  of  vision,  as  well  as  the  diminution  of  central 
vision  with  concentric  limitation  of  the  field  of  vision, 
do  not  depend  on  diminished,  out  on  increased  irri- 
tability of  the  retina — not  on  anaesthesia,  but  on  hy- 
percBsthesia  of  the  retina,  so  the  sensitiveness  to  light, 
rapid  weariness  of  the  eye  at  work,  photophobia,  fiashes 
of  light  and  sparks  before  the  eyes,  are  manifestations 
of  irritation  propagated  from  the  one  optic  nerve  to 
the  other.  The  eye  wjiich  has  become  over-irritated  by 
the  sympathetic  process  refuses  periodically,  or  perma- 
nently, to  react  in  various  portions  of  its  field  of  vision, 
to  the  irritation  of  an  amount  of  light  which  would 
be  plenteonsly  sufficient  for  an  eye  in  a  state  of 
normal  excitability.  Anc^  further  in  this  connection, 
we  must  remember  that  v.  Graefe  long  since  rightly 
referred  to  hypercesthesia  of  the  retina,  that  anaesthesia 
of  the  retina,  with  concentric  limitation  of  the  field  of 
vision,  which  we  observe  in  cases  where  there  can  be 
no  question  of  sympathetic  irritation. 

Some  one  may  ask  how  it  is  possible  for  such  a  con- 
nection to  exist  between  the  eyes,  by  means  of  the  op- 
tic nerves,  in  those  cases  in  which  the  optic  nerve  of  the 
e}re  first  afi'ected  is  in  a  state  of  total  atrophy.  A  cord 
of  connective  tissue  cannot  transmit  such  a  sensorial 
irritation !  Granted  ;  but  even  if  this  is  so,  we  can- 
not, in  my  opinion,  assume  with  absolute  certainty,  in 
all  those  cases  in  which  similar  functional  disturb- 
ances are  observed,  without  any  material  foundation 


PATIIOGENY.  129 

in  the  second  eye,  that  all  the  fibres  of  the  optic  rerve 
of  the  firsfc  eye  are  atrophic.  How  could  we  decide, 
even  with  the  microscope,  that  some  minute  fibres 
which  still  had  the  capacity  of  acting  like  nerve-ele- 
ments, or  axis-cylinders  deprived  of  their  medulla, 
might  not  still  be  present  in  the  connective- tissue 
cord  into  which  the  optic  nerve  had  become  trans- 
formed ?  When  Brecht,  therefore,  thinks  it  impossi- 
ble that  the  optic  nerves  could  have  transmitted  the 
sympathetic  irritation  in  his  case,  and  falls  back  on 
the  ciliary  nerves  in  order  to  support  a  theory  of  his 
own,  he  raises  an  unanswerable  argument  against  him- 
self, by  saying  that  the  eye  first  affected  was  perfectly 
free  from  pain  and  irritation.  In  other  words,  his 
supposition  of  an  irritative  condition  of  the  ciliary 
nerves  falls  to  the  ground.  We  do  not,  however, 
mean  to  assert  that  the  functional  disturbances  of  the 
retina,  which  have  been  previously  mentioned,  do  not 
depend  upon  alterations  in  the  tissue  concerned,  even 
when  the  ophthalmoscopic  image  is  negative.  For  we 
shall  be  compelled  to  assume  some  structural  changes, 
even  though  they  be  coarse,  when  the  irritation  does 
not  disappear  after  the  source  of  irritation  has  been 
removed.  Thus,  in  Alfred  Graefe's  terrible  case 
(page  65),  in  which  the  tormenting  photopsies  did  not 
yield  after  enncleation  of  the  injured  eye,  I  cannot 
doubt  that  they  originated  in,  and  were  kept  up  by, 

the  products  of    inflammation  which   had    already 
6* 


130  SYMPATHETIC   DISEASES   OF   THE   EYE. 

taken  firm  hold  of  the  optic  nerves.  The  microsco- 
pist,  in  these  cases,  gives  us  an  important  clue  in  this 
direction,  when  he  finds  proliferated  connective  tissue 
in  the  intraocular  end  of  the  optic  nerve  belonging 
to  the  enucleated  eye.  Such  a  proliferation  of  inter- 
stitial connective  tissue  in.  the  tract  of  the  optic  nerve 
would  gradually  compress  the  bundle  of  nerve-fibres 
more  and  more  closely,  and  finally  give  rise  to  mere 
mechanical  irritation. 

In  previously  speaking  of  evident  inflammation  of 
the  optic  nerve  and  retina  of  the  second  eye,  we  took 
occasion  to  emphasize  the  fact  that  there  is  no  hinder- 
ance  whatever  to  the  transmission  of  such  a  process 
from  one  eye  to  the  other.  We  had  only  to  prove 
that  such  a  neuro-retinitis  was  really  present  in  the 
eye  first  affected.  Indeed,  I  should  like  to  believe 
that,  when  the  retina  and  optic  nerve  of  the  first  eye 
have  been  found  intact  after  enucleation  in  a  few 
cases  of  assumed  sympathetic  neuro-retinitis,  this  very 
fact  alone  takes  away  every  point  of  support  in  favor 
of  the  sympathetic  origin  of  the  affection  in  question. 

We  now  see  why  I  so  long  ago  emphasized  the 
opinion  that  inflammatory  affections  of  the  nervous 
apparatus  of  the  second  eye  really  occur  -more  fre- 
quently than  observers  have  hitherto  been  inclined  to 
admit,  as  well  as  that  their  presence  is  frequently  hid- 
den by  the  simultaneous  appearance  of  irido-cyclitis ; 
and,  finally,  that  there  is  no  necessity  whatever  for  as- 


PATHOGEN  Y.  131 

suming  that  they  simply  indicate  the  extension  of  the 
inflammatory  process  from  the  choroid  of  the  same 
eye.     Nor  should  we  forget,  in  speaking  generally  of 
the    transmission   of    inflammation    along    the   optic 
nerves,  that  this  might  also  happen  in  case  the  optic 
nerve  of  the  eye  first  affected  were  completely  trans- 
formed into  a  thread  of  connective  tissue.     For,  even 
in  such  a  structure  as  this,  the  inflammation  might 
creep  onward  to  the  chiasma,  and  then  appear  in  the 
trunk  of  the  second  optic  nerve  in  the  shape  of  a  dan- 
gerous peri-neuritis,  embracing  and  crushing  the  fibres 
of  the   optic   nerve    by   proliferation   of    connective 
tissue  (a  process  which  might  finally  reveal  itself  to 
the  ophthalmoscope  by  partial  or  total  atrophy  of  the 
optic  papilla) ;  or  it  might  advance  as  far  as  the  optic 
papilla,  and  there  present  itself  to  the  eye  of  the  ob- 
server under  the  form  of  optic  neuritis.     If  we  once 
hold  fast  to  the  fact  that  the  optic  nerve  offers  a  very 
productive  territory  for  the  propagation  of  inflamma- 
tion, we  can  then  oomprehend  why  optic  neuritis  may 
appear  in  the  second  eye  after  enucleation  of  the  first, 
as  in  Colsmann's  three  cases  previously  cited  (page 
93).     For,  in  these  cases,  the  inflammation  was  either 
under  way  at  the  time  when  the  operation  was  per- 
formed, and  was  only  rapidly  increased  by  the  opera- 
tion, or  else  the  operation  led  to  the  neuritis  by  crush- 
ing the  nerve  during  its  division.     Such  a  crushed 
condition  of  the  nerve  was  indeed  directly  acknowl- 


132  SYMPATHETIC   DISEASES   OF   THE   EYE. 

edged  by  Moore n,  in  a  case  which  he  observed  long 
before  (1860)  the  cases  cited  by  Colsmann.  The  pa- 
tient began  to  complain  of  increasing  dimness  of 
vision,  photopsia,  and  slight  pressure  in  the  forehead, 
a  few  weeks  after  the  enucleation  of  the  injured  eye. 
Corrosive  sublimate  was  exhibited  internally,  and  a 
seton  placed  in  the  neck ;  but  several  months  passed 
before  the  subjective  symptoms  disappeared  entirely. 
The  final  history  of  the  case  showed  that,  two  years 
later,  atrophic  alterations  in  the  optic  nerve  (as  con- 
firmed by  the  ophthahnoscopic  examination)  had  re- 
duced the  patient's  vision  so  much  that  he  felt  for- 
tunate in  being  able  to  read  Jaeger's  test-types  >.'<>. 
12,  with  difficult}'.  Who  would  not  seek  to  explain 
such  a  case  as  this  in  the  most  simple  way,  by  imagin- 
ing that  the  operation  gave  rise  to  a  peri-neuritis 
which  extended  to  the  second  optic  nerve,  and  pro- 
duced partial  atrophy? 

We  have,  on  the  whole,  no  right  at  all  to  aslc 
whether  the  sympathetic  affection  is  transmitted  along 
the  optic  nerves,  or  along  the  ciliary  nerves  ;  nor  can 
we  ask  whether  the  transmission  takes  place  along  t/ie 
one  path  more  frequently  than  along  the  other.  For 
the  transmission  may  be  effected  in  both  ways.  But 
by  this,  however  ^  we  are  not  to  understand  that  one 
and  the  same  morbid  process  can  be  transmitted,  now 
along  the  one  path,  and  now  along  the  otlier.  On  the 
contrary )  irritative  and  inflammatory  conditions  are 


PATHOGEN  Y.  133 

transmitted  from  the  optic  nerve  and  retina,  along 
the  optic  nerves;  whilst  those  inflammatory  processes 
which  are  chiefly  observed  in  that  portion  of  the  eye 
which  is  nourished  by  the  ciliary  nerves,  and  espe- 
cially in  the  uveal  tract,  are  transmitted  along  the 
ciliary  nerves.  There  is  not  the  least  doubt  that  the 
sympathetic  inflammation  may  frequently  he  trans- 
mitted along  both  paths  at  once,  or  at  short  intervals, 
so  that  many  symptoms  in  sympathetic  affections  of 
the  uveal  tract  (amongst  others,  the  functional  dis- 
turbances) are  not  to  be  attributed  to  the  inflam- 
mation of  the  uveal  tract,  but  to  a  simultaneous  in- 
flammation of  the  retina  and  optic  nerve. 

This,  of  course,  does  not  exclude  the  possibilit}T  of 
detachment  of  the  retina,  appearing  in  connection 
with  the  irido-choroiditis,  involving  the  sympatheti- 
cally affected  eye,  just  as  it  may  he  observed  in  every 
irido-choroiditis.  In  the  same  way,  when  we  see  sym- 
pathetic neuro-retinitis  in  this  same  eye,  the  final  de- 
tachment of  the  retina  is  not  due  to  a  sympathetic 
inflammation  of  the  latter  tissue,  but  to  the  process 
which  is  going  on  in  the  choroid. 

Moreover,  as  any  irritation  of  the  stump  of  the 
nerve,  external  to  the  eye,  can  induce  sympathetic 
neuro-retinitis,  it  is  easy  to  see  (if  we  once  acknowl- 
edge that  the  ciliary  nerves,  or,  in  a  wider  sense,  the 
branches  of  the  trigeminus,  can  transmit  the  irritation) 
not  only  how  cyclitis  of  the  one  eye  can  prod'1- 


134:  SYMPATHETIC   DISEASES   OF   THE   EYE. 

affections  of  the  whole  choroidal  tract  in  the  other, 
but  also  how  the  same  morbid  processes,  which  excite 
sympathetic  affections  in  the  ciliary  body  by  irritat- 
ing the  ciliary  nerves,  can  similarly  become  an  irri- 
tating cause  in  other  regions  of  the  eye,  as  well  as 
outside  the  eye,  so  soon  as  the  filaments  of  the  trige- 
rninus,  which  are  distributed  to  the  regions  concerned, 
are  affected  in  an  analogous  manner.  From  all  this 
we  see  that  it  is  by  no  means  extraordinary  for  irrita- 
tion (incarceration),  or  inflammation  of  the  iris,  or  of 
the  choroid  itself,  or  for  the  irritation  caused  by  an 
artificial  eye  resting  upon  a  stump,  or  finally,  for  the 
mere  introduction  of  an  artificial  eye  into  the  orbit 
after  removal  of  the  eye,  to  develop  in  the  second 
eye  about  the  same  train  of  symptoms  that  we  observe 
after  a  genuine  cyclitis  in  the  first  eye.  In  the  latter 
point  of  view  (the  influence  of  an  artificial  eye), 
Mooren  was  distinctly  able  to  prove,  in  a  case  with 
great  tenderness  over  the  whole  region  of  the  stump 
of  the  optic  nerve,  how  even  a  slight  touch,  upon  the 
inner  wall  of  the  orbit,  produced  excessive  pain — a 
fact  which  would  go  to  demonstrate  that  the  region 
to  which  the  naso-ciliaris  nerve  is  distributed  was 
irritated  by  the  sharp  edges  of  the  artificial  eye. 
Moreover,  a  case  of  Snellen's,  in  which  the  sympa- 
thetic phenomena  of  irritation  could  at  pleasure  be 
excited  and  then  dissipated,  depending  upon  whether 
the  artificial  eye  was  inserted  or  again  removed,  shows 


PATHOGENY.  135 

how  much  these  phenomena  in  the  second  eye  may 
depend  upon  the  irritation  of  the  empty  orbit  by  the 
glass  shell. 

Furthermore,  we  can  see  how  enucleation  itself,  by 
crushing  the  ciliary  nerves  (and  optic  nerve)  during 
their  division,  can  become  the  starting-point  of  sym- 
pathetic inflammation,  as  well  as  how  the  curative 
reaction  after  a  normal  enucleation  can  excite  the 
destructive  disease  in  question  by  contracting  the 
stump  of  the  nerve  in  the  cicatrix.  In  the  same  way 
it  is  easy  to  understand  that,  when  the  process  in  the 
first  eye  has  once  overstepped  the  rubicon,  and  is 
already  advancing  toward  the  chiasma  along  the  ex- 
tra-ocular tracts,  enucleation  cannot  prevent  its  en- 
trance into  the  interior  of  an  eye  which  is  still  intact ; 
and  finally,  that  even  when  the  cyclitis  (or  neuro- 
retinitis)  in  the  first  eye  is  entirely  cured,  the  same 
process  may  subsequently  appear  in  the  second  eye, 
and  there  continue  its  devastating  course.  The  enemy 
had  indeed  wholly  evacuated  his  first  camping-ground, 
but  at  the  same  time  he  was  already  advancing  rap- 
idly upon  the  second  eye. 

Now,  just  as  I  have  seen  cyclitis  appear  in  the 
second  eye  after  complete  recovery  from  the  same 
disease  in  the  other,  or  seen  the  second  eye  exhibit 
the  most  violent  type  of  cyclitis  despite  the  fact  that 
the  other  eyeball  was  perfectly  free  from  spontaneous 
pain,  as  well  as  insensible  to  the  touch,  it  might  not 


136  SYMPATHETIC   DISEASES   OF   THE   EYE. 

be  at  all  impossible,  after  a  normal  recovery  from 
enncleation,  for  some  source  of  irritation  to  remain  in 
the  orbital  or  intracranial  fibres  of  the  nerve  in- 
volved. I  think  that,  in  every  case  in  which  we  have 
been  obliged  to  ascribe  the  outbreak  of  sympathetic 
symptoms  to  the  enucleation  itself,  or  to  the  introduc- 
tion of  an  artificial  eye,  we  have,  so  far,  observed,  that 
the  region  in  the  bottom  of  the  orbit  which  was  occu- 
pied by  the  stump  of  the  excised  nerve,  and  its  ac- 
companying ciliary  nerves,  was  sensitive  to  the  touch, 
as  well  as  that  the  conjunctiva  lining  the  cavity  was 
swollen,  red,  and  painful.  On  the  other  hand,  it 
would  seem  unjustifiable  for  us  not  to  recognize  the 
characteristic  appearances  of  sympathetic  irritation, 
as  such,  simply  because  up  to  this  time  we  had  never 
observed  them  in  the  absence  of  tenderness  in  the 
orbit,  as  well  as  at  the  stump  of  the  nerve.  I  allude 
now  to  the  following  case : 

o 

March  25,  1878,  I  saw,  for  the  first  time,  a  farmer, 
aged  forty-three,  who  had  been  wounded  more  than  a 
year  before,  in  the  right  eye,  by  the  thrust  of  a  cow's 
horn.  A  few  days  after  the  accident,  violent  pain  was 
felt  all  over  the  corresponding  side  of  the  head.  The 
injured  eye  was  enucleated  at  a  later  date,  but  the  pain 
did  not  cease.  A  year  has  passed  since  the  enucleation, 
but  the  patient  lias  never  been  free  from  exacerbat- 
ing attacks  of  pain  on  the  right  side  of  his  head.  Still 
lie  does  not  seek  advice  so  much  for  the  pain,  as  be- 


PATHOGEN  Y.  137 

cause  his  left  eye  is  totally  unfit  for  loorJc.  He  can 
use  it  so  little,  that  it  is  only  with  the  greatest  difficulty 
that  he  can  carry  on  his  farm-work.  He  cannot  read 
at  all  for  more  than  a  moment  or  two  at  a  time.  The 
eye  looks  normal  externally  and  the  ophthalmoscope 
does  not  help  me  to  discover  any  internal  alterations. 
The  patient  can  read  diamond  type  (Jaeger  No.  1),  and 
his  field  of  vision  is  normal.  The  only  definite  anom- 
aly which  one  can  discover  in  the  eye  is  that  the 
power  of  accommodation  is  somewhat  less  than  is 
usual  at  the  patient's  age.  Despite,  however,  this 
nearly  normal  condition  of  the  eye,  the  patient  cannot 
work  for  any  length  of  time,  even  with  a  convex  glass 
to  support  his  accommodation.  We  are  therefore  led 
involuntarily,  in  such  a  case  as  this,  to  assume  the  pres- 
ence of  a  sympathetic  neurosis.  But  when  we  exam- 
ine the  right  orbit,  we  find  that  the  cavity  is  lined  with 
a  conjunctiva  which  is  neither  red  nor  swollen,  while 
neither  in  the  bottom  of  the  orbit,  nor  over  the  loca- 
tion of  the  stump  of  the  optic  nerve,  can  we  discover 
any  tenderness,  nor  even  any  special  sensitiveness  to 
pressure  with  a  blunt  probe.  These  various  reasons 
had  led  several  oculists  to  deny  the  possibility  of  any 
sympathetic  affection  in  this  case ;  but  I  do  not  regard 
it  as  entirely  impossible.  The  irritative  cause,  even  if 
the  peripheral  ends  of  the  nerves  show  no  distinct 
anomaly,  may  lie  anywhere  in  the  nerve-tracts ;  possi- 
bly even  in  the  orbital  portion  of  the  optic  nerve.  In 


138  SYMPATHETIC   DISEASES   OF   THE   EYE. 

such  a  case,  some  remedy  may  yet  be  discovered  by 
scientific  investigation. 

o 

Another  question  now  arises  in  considering  the 
pathogeny  of  sympathetic  affections :  If  we  take  it 
for  granted  that  the  nerves  transmit  the  irritation,  do 
we  know  anything  more  accurate  regarding  the  method 
of  transmission  ?  We  need  not  trouble  ourselves  be- 
cause, in  the  present  state  of  our  knowledge,  "  it  is  im- 
possible for  us  to  know  anything  "  about  the  molecular 
alterations  which  may  be  present  in  the  nerves  during 
the  conduction  of  the  irritation.  But  it  is  a  more 
striking  fact  that  we  really  know  nothing  more  pre- 
cise as  regards  the  manner  in  which  inflammation  is 
transmitted.  But  even  in  this  point  of  view  we  must 
distinguish  between  the  ciliary  nerves  and  the  optic 
nerve. 

Alt  searched  for  alterations  in  the  ciliary  nerves  in 
one  hundred  and  ten  cases  in  our  province,  but  found 
only  forty- three  which  offered  any  direct  testimony. 
Thirty-four  of  these  cases  showed  normal  ciliary 
nerves.  The  remainder  showed  various  lesions  of  the 
nerves  in  question,  such  as  tearing,  crushing  (without 
histological  alterations),  incarceration  in  a  cicatrix,  fatty 
degeneration,  atrophy,  thickening  of  Schlemm's  canal, 
and  one  case  of  calcareous  degeneration  in  the  same 
canal. 

Goldzieher  (1877)  thought  that  he  had  unravelled 
the  mystery,  when  he  discovered  in  a  given  case 


PATHOGENY.  139 

(which  in  my  opinion  is  very  doubtful,  so  far  as  re- 
gards its  genuinely  sympathetic  origin)  such  extensive 
alterations  in  the  ciliary  nerves  of  the  enucleated  eye 
as  no  other  observer  had  ever  before  seen.  The  whole 
thickness  of  the  choroid  was  filled  with  fresh  inflam- 
matory swelling  and  proliferation  of  cells ;  whilst  the 
sheaths  of  the  ciliary  nerves  were  thickly  infiltrated 
with  round  cells,  and  the  inter-tibrillar  tissues  crowded 
with  granules.  Inflammatory  nodules  composed  of 
round  cells  were  also  seen  here  and  there  compressing 
the  trunks  of  the  optic  nerves.  If  such  a  condition  as 
this  were  more  generally  observed,  we  should  have  at 
least  some  anatomical  proof  that  the  ciliary  nerves 
are  capable  of  propagating  the  inflammatory  process 
within  the  eye,  as  has  already  been  proved  in  the  case 
of  the  optic  nerves,  even  if  we  have,  so  far,  been  wholly 
unable  to  determine  with  exactitude  the  paths  along 
which  the  inflammatory  process  is  transmitted,  outside 
the  eye.  But  Goldzieher's  discovery  is  very  excep- 
tional, and  it  cannot  be  denied  that,  in  a  vast  major- 
ity of  cases,  the  ciliary  nerves  of  the  eye  which  excites 
the  sympathy  show  no  alterations  whatever.  Goldzie- 
her  takes  it  for  granted  that  the  inflammatory  altera- 
tions which  he  observed  in  the  ciliary  nerves  are  in- 
variably present  in  such  cases,  and  assumes,  in  corre- 
spondence with  the  experiments  made  on  animals  by 
Tiesler,  Feinberg,  Klemm,  and  Niedieck,  that  the  in- 
flammation in  these  nerves  does  not  advance  continu- 


140  SYMPATHETIC   DISEASES   OF   THE   EYE. 

ously,  but  by  fits  and  starts,  and  that  when  it  has 
reached  the  central  organ  it  extends  still  farther  in  a 
similar  manner.  When  the  inflammation  has  finally 
crossed  over  to  the  nerve-tracts  of  the  opposite  side,  it 
propagates  itself  in  the  same  way,  and  so  reaches 
in  due  season  the  network  of  nerves  in  the  interior  of 
the  second  eye,  along  which,  in  turn,  the  dangerous  in- 
flammation is  conducted  to  the  various  membranes  in 
correspondence  Avith  the  distribution  of  the  nerves 
concerned.  So  much  for  Goldzieher's  opinion,  to 
which  we  may  reply  that  the  theory  of  a  wandering 
neuritis,  as  the  anatomical  cause  of  sympathetic  in- 
flammation, lacks  at  present  any  satisfactory  basis, 
from  the  very  fact  that  in  almost  every  case  the  in- 
traocular ciliary  nerves  are  decidedly  intact,  to  say 
nothing  of  the  fact  that  no  one  has  ever  yet  demon- 
strated such  a  wandering  neuritis,  nor  proved  how 
such  an  inflammation  in  a  nerve  (even  were-  it  demon- 
strated anatomically)  could  cause  violent  inflammation 
in  a  connective  tissue. 

Dark  and  complicated,  therefore,  as  must  seem  the 
possible  way  in  which  inflammatory  processes  are  trans- 
mitted along  the  ciliary  nerves,  the  matter  is  relatively 
simple  in  the  case  of  the  optic  nerves,  for  in  the  lat- 
ter we  have  only  to  picture  the  transmission  of  an  in- 
flammation from  nerve  to  nerve.  Under  such  cir- 
cumstances as  these,  the  inflammation  of  the  optic 
nerve,  in  the  injured  eye,  is  anatomically  proved — in 


PATHOGENY.  141 

the  eye  affected  sympathetically,  it  is  directly  proved 
with  the  ophthalmoscope  ;  so  that  here,  \viththe  union 
of  the  optic  nerves  at  the  chiasma,  we  may  calmly  as- 
sume that  we  have  to  do  with  a  connected  or  discon- 
nected neuritis,  passing  from  one  nerve  to  the  other 
through  the  chiasma. 

Another  important  question  for  us  to  decide  is  this : 
How  long  does  it  take  for  the  irritation  which  ad- 
vances along  the  nerve-tracts  to  reach  the  second  eye  ? 
This  is  about  the  same  as  to  ask  when  the  sympathetic 
inflammation  is  liable  to  appear.  We  may  at  once 
reply  that  we  cannot  fix  the  latest  period  at  which  the 
disease  in  question  may  make  its  appearance.  If  an 
eye  is  totally  destroyed  by  an  injury,  the  possibility  of 
its  reacting  upon  the  second  eye  continues,  not  only 
so  long  as  the  eye  is  painful,  but  in  case  a  foreign 
body  has  remained  harmlessly  in  the  eye  (even  at  any 
region  whatsoever),  it  may  at  any  indefinite  future 
time  be  followed  by  a  reaction  due  to  the  presence  of 
the  foreign  body  (page  24).  Or  further,  in  an  atro- 
phic  eye  which,  being  utterly  free  from  irritation, 
seems  an  extremely  harmless  neighbor,  some  un- 
known cause,  or  the  development  of  a  plate  of  bone 
in  its  interior,  may  give  rise  to  renewed  sensitiveness, 
and  consequently  develop  a  posthumous  source  of  irri- 
tation (page  49).  Finally,  there  can  scarcely  be  any 
doubt  that,  in  &  painless  and  unirritable  stump  or  eye- 
ball, the  seeds  of  sympathetic  irritation  can  rest  un- 


142  SYMPATHETIC   DISEASES   OF   THE    EYE. 

germinated  for  an  indefinite  period  (pages  48  and  67). 
In  point  of  fact,  literature  gives  us  the  history  of  cases 
in  which  tens  of  years,  even  half  a  century,  or  longer 
periods,  have  elapsed  between  the  original  injury,  or 
exciting  cause,  and  the  development  of  sympathetic 
ophthalmia. 

It  is  much  more  important,  however,  for  us  to  de- 
termine the  earliest  period  at  which  the  sympathetic 
affection  may  appear.  In  this  point  of  view  a  pro- 
portionately long  interval  seems,  in  our  opinion,  to 
exist  between  the  cause  and  the  result.  A  priori,  this 
interval  cannot  be  measured.  We  have  no  precise 
starting-point  from  which  to  discover  how  long  it 
takes  for  the  morbid  condition  in  the  ciliary  and  optic 
nerves  to  be  transmitted  to  the  opposite  side.  So  that, 
while  the  earliest  appearance  of  neuro-retinitis  in  the 
injured  eye  has  been  precisely  demonstrated,  we  do 
not  know,  so  far  as  regards  the  ciliary  nerves,  how 
long  a  time  must  elapse  before  the  ciliary  nerves  in 
\\\e  primarily  affected  eye  are  excited  to  the  necessary 
irritative  condition.  We  might  even  believe  that 
sympathetic  neuro-retinitis  must  necessarily  be  devel- 
oped in  a  ranch  shorter  time  than  sympathetic  cyclitis, 
because  the  path  along  which  the  cyclitis  advances  is 
much  longer  than  in  the  case  of  the  neuro-retinitis  ; 
nevertheless,  we  could  by  no  means  affirm  that  our 
experience  corresponds  to  our  expectation.  Macken- 
zie stated  that  from  one  month  to  a  month  and  a  half 


PATHOGENY.  143 

separated  the  original  from  the  induced  affection,  and 
I  must  emphasize  the  fact  that,  in  my  own  experience, 
I  know  of  no  case  in  which  I  ever  saw  sympathetic 
ophthalmia  appear  sooner  than  in  four  weeks  after 
the  injury.  I  grant,  indeed,  that  this  period  of  four 
weeks  might  be  somewhat  shortened,  in  occasional 
cases,  but  I  will  not  grant  that  the  necessary  period 
can  be  reducetl  to  a  few  days,  as  is  alleged  to  have 
been  observed  by  several  authors.  There  are,  however, 
some  observations  after  enucleation,  which  would 
seem  to  argue  in  favor  of  the  possibility  of  the  rapid 
development  of  the  sympathy,  although  they  deserve 
to  be  carefully  examined.  We  saw  (page  94r)  how 
Colsmann  and  Hugo  Miiller  both  observed  one  case 
each  of  neuro-retinitis  in  the  uninjured  eye  a  few 
days  after  enucleation  of  the  other,  and  similar  ob- 
servations are  at  hand  in  respect  to  uveal  inflamma- 
tions (v.  Graefe,  Mooren,  Schmidt,  Pagenstecher,  and 
Genth).  But  before  we  accuse  enucleation  of  being 
the  cause  of  the  sympathy  in  these  cases,  we  must 
prove  that  such  an  interval  had  not  elapsed  since  the 
injury,  as  would  have  enabled  the  sympathetic  inflam- 
mation to  appear  at  that  very  same  time,  even  if  the 
enucleation  had  not  been  done,  owing  to  the  fact  that 
the  sympathetic  irritation  had  long  ago  started  on  its 
path,  and  was  just  on  the  point  of  making  its  appear- 
ance in  the  other  eye  when  the  enucleation  happened 
to  be  performed.  "When,  in  the  case  of  the  last  two 


144  SYMPATHETIC   DISEASES- OF   THE   EYE. 

authors,  the  first  symptoms  of  sympathetic  iritis  re- 
vealed themselves  in  the  previously  healthy  eye  nine 
days  after  the  enucleation,  we  must  remember  that 
thirty-six  days  had  already  passed  since  the  original 
injury — a  period  in  which  the  outbreak  of  sympathetic 
ophthalmia  cannot  surprise  us,  for  it  could  not,  at  that 
late  period,  have  been  restrained  by  an  enucleation 
performed  only  nine  days  before.  Scfimidt's  case  is 
somewhat  similar:  sympathetic  inflammation  appears 
in  four  days  after  the  enucleation ;  but  hero,  also, 
nearly  four  weeks  have  elapsed  since  the  injury. 
When  enucleation  is  performed  in  the  case  of  eyes 
which  have  for  a  long  time  been  phthisical  and  pain- 
ful (Colsmann  and  II.  Miiller),  the  sympathy  which 
appears  in  a  few  days  after  enucleation  can,  with  all 
the  less  certainty,  be  referred  to  the  operation.  So,  if 
we  have  pure  cases — i.e.,  if  one  of  two  previously 
healthy  eyes  is  seriously  injured,  sympathetic  irrita- 
tion will  rarely  appear  before  the  fourth  week ;  nor. 
when  fairly  under  way,  can  it  be  restrained  by  enuclea- 
tion. 

The  fact  that  a  certain  interval  must  elapse  between 
the  affection  of  the  one  eye  and  sympathy  in  the  other 
is  of  great  importance  in  establishing  our  diagnosis  of 
a  sympathetic  disease.  In  order  to  make  such  a 
diagnosis  in  any  given  case,  we  must  weigh  well  all 
that  has  previously  been  given  in  detail  in  these  pages, 
under  the  sections  of  Etiology  and  Pathology.  Fur- 


PATHOGENY.  145 

thermore,  as  we  have  already  given  a  sufficient  ac- 
count of  the  general  course  and  results  of  the  more 
important  types  of  sympathetic  ophthalmia,  especially 
as  regards  irritation,  and  the  manifold  forms  of 
affections  of  the  uveal  tract,  we  can  at  this  place  dis- 
pense with  any  special  remarks  on  the  prognosis  of 
the  disease  in  question.  And  so  much  the  more  read- 
ily, as  several  points  in  this  respect  will  be  mentioned 
under  the  title  of  Therapeutics,  to  which  we  will  now 
give  our  attention. 


SECTION    V. 


THERAPEUTICS. 

WE  finally  turn  our  attention  to  th-3  therapeutics  of 
sympathetic  ophthalmia,  and  instantly  we  hear  the 
cry — I  might  almost  say  the  battle-cry,  "  Enuclea- 
tion."  Scarcely  twenty  years  have  passed  away  since 
v.  Graefe  said :  "  I  should  never  think  it  necessary  to 
undertake  the  complete  extirpation  of  an  eye  affected 
with  traumatic  irido-choroiditis,  in  order  to  ward  off 
a  sympathetic  affection  from  the  other  eye,  and  1 
only  mention  this  operation  because,  as  I  hear,  it  is 
performed  by  some  English  oculists.^  Since  then, 
thousands  upon  thousands  of  eyes  have  been  sacri- 
ficed, and  where  is  the  oculist  who  feels  wholly  inno- 
cent of  having  operated  under  the  philanthropical 
mantle  of  preventive  enucleation,  just  for  the  sake  of 
gaining  some  especially  desirable  specimen  for  his 
pathological  collection  ? 

Let  us,  however,  enter  calmly  upon  our  discussion 
of  this  highly  important  subject.  Before  showing  the 


THERAPEUTICS.  14:7 

beneficial  results  which  enucleation  may  win  for 
the  patient,  let  us  first  inquire  into  the  harm  which  it 
may  cause.  The  most  terrible  result  of  enuclea- 
tion (an  operation  which  consists  in  shelling  out 
the  eyeball  from  its  surrounding  capsule  of  Tenon, 
sparing  as  much  as  possible  of  the  conjunctiva  of  the 
globe,  as  well  as  of  the  external  muscles  of  the  e}re) 
is — deatli !  V.  Graefe  witnessed  two  deaths,  when  he 
enucleated  during  the  period  of  purulent  panophthal- 
mitis,  but  none  under  any  other  circumstances.  On 
the  other  hand,  however,  several  fatal  cases  have  been 
reported  after  enucleation  of  an  eyeball  which  was 
not  affected  with  purulent  panophthalmitis  (Mann- 
hardt,  Horner,  Just,  H.  Pagenstecher,  Yerneuil,  and 
Yignaux).  The  fatal  cases  reported  by  Horner,  Pa- 
genstecher, and  Yerneuil  were  due  to  meningitis,  as 
was  demonstrated  at  the  post-mortem  examinations, 
although  in  the  first  two  cases  there  was  no  evident 
proof  that  the  process  had  extended  from  the  orbit ; 
while  in  Yerneuil's  patient  a  pblegmonous  inflamma- 
tion of  the  orbit  was  proved  to  be  the  connecting 
link.  1,  also,  once  saw  a  fatal  result  after  enucleation, 
in  the  case  of  an  old  woman  whose  right  eye,  after 
having  undergone  an  iridectomy,  continued  painful, 
and  had  to  be  enucleated  on  account  of  absolute 
glaucoma.  Profuse  hemorrhage  followed  the  opera- 
tion, and  death  ensued  in  a  few  days.  The  orbit  ex- 
hibited traces  of  suppuration,  but  there  were  no  signs 


148  SYMPATHETIC   DISEASES    OF    THE   EYE. 

of  meningitis.  On  the  whole,  there  was  no  discover- 
able cause  of  death.  There  have  undoubtedly  been 
many  more  cases  of  death  after  enucleation  than 
have  ever  appeared  in  print.  For  all  that,  we 
shall  see  how  mere  chance  may  play  its  role  in 
this  accident,  from  a  case  of  my  own,  which  will  not 
easily  be  erased  from  my  memory.  An  old  woman 
had  suffered  for  years  with  violent  pain  in  a  blind 
glaucomatous  eye,  which,  with  loss  of  sleep  and  appe- 
tite, had  reduced  her  to  a  very  feeble  condition.  At 
last  she  made  up  her  mind  to  have  the  enucleation 
performed,  ancl  was  received  into  the  hospital.  I  post- 
poned the  operation  for  some  reason  or  other,  to  the 
following  day.  But  the  operation  was  never  performed, 
for  on  the  morning  of  the  day  appointed,  the  patient 
was  found  dead  in  her  bed.  Had  I  operated  on  the 
day  before,  who  is  there  who  conld  not  have  said  that 
the  operation  killed  the  patient  ?  The  autopsy  in  this 
case,  as  usually  happens,  revealed  no  cause  for  death.* 
We  are  next  to  notice  that  the  enucleation  of  eyes 
which  are  sacrificed  in  order  to  protect  the  second  eye 
does  not  always  progress  without  accidents,  leaving 

*  As  partially  bearing  on  the  question  of  chance,  let  us  recall  a 
case  of  our  own,  in  which  an  iridectomy  was  appointed  for  a  cer- 
tain day,  in  a  case  of  glaucoma.  On  the  morning  of  the  day  ap- 
pointed, the  patient  was  found  dead  in  her  bed.  Ought  not  the 
extremely  few  cases  of  reported  death  from  iridectomy  to  be  attri- 
buted to  some  other  than  the  alleged  cause  ? — TRS. 


THERAPEUTICS.  149 

aside  the  very  distant  possibility  of  death.  We  may 
have  extensive  purulent  inflammation  of  the  orbital 
tissues  without  being  able  to  discover  any  cause  for 
such  a  course  of  events  in  the  case  itself,  or  in  the 
operation ;  intense  phlegmonous  swelling,  accompa- 
nied with  violent  pain,  may  be  developed  in  the  orbit 
and  lids,  compelling  us  to  make  an  exit  for  the  pus 
by  extensive  incisions  into  the  orbital  tissues  and  sur- 
rounding parts.  At  the  same  time,  the  general  condi- 
tion of  the  patient  is  weakened,  and  we  can  congratu- 
late ourselves  when  the  process  confines  itself  to  the 
orbit,  so  that  all  fear  of  its  spreading  into  the  cranial 
cavity  is  removed. 

Again,  enucleation  always  causes  a  local  disfigure- 
ment, respecting  the  degree  of  which  there  may, 
however,  be  different  opinions.  Moreover,  in  so  far 
as  the  eye  removed  had  a  certain  size,  and  the  opera- 
tion was  performed  on  a  child,  enucleation  has  con- 
siderable influence  upon  the  configuration  of  the  orbit 
concerned,  as  well  as  of  the  corresponding  side  of  the 
face.  There  may  of  course  be  some  discussion,  in 
so  far  as  regards  the  local  disfigurement,  as  to  which 
is  the  more  comely,  an  empty  orbit  with  sunken  eye- 
lids (which,  however,  every  one  will  cover  with  a 
handkerchief  or  bandage),  or  a  misshapen  stump, 
which  cannot  easily  or  agreeably  be  kept  constantly 
covered.  To  be  sure,  we  shall  hear  in  reply  that  the 
difference  really  consists  in  this :  that  an  artificial  eye, 


150  SYMPATHETIC   DISEASES   OF   THE   EYE. 

fitted  upon  the  stump,  satisfies  the  cosmetic  demands 
more  perfectly  than  when  it  is  inserted  into  a  vacant 
orbit.  The  artificial  eye,  a  hollow  glass-shell,  with  its 
concavity  applied  in  corresponding  size  and  curvature 
to  the  convex  stump,  deceives  every  one  by  the  com- 
plete mobility  which  is  imparted  to  it  by  the  muscles 
still  fixed  to  their  normal  attachments — a  real  eye,  so 
true  to  nature  as  often  to  deceive  even  the  specialist, 
if  he  does  not  look  very  carefully.  It  may,  indeed, 
happen  that  the  specialist  himself  mistakes  the  one 
for  the  other,  the  artificial  for  the  natural,  and  the 
natural  for  the  artificial  eye.  tff  the  concave  shell  of 
the  artificial  eye  is  inserted  into  an  orbit  which  has 
been  deprived  of  its  eye,  the  mobility  of  the  former  is 
not,  as  is  generally  supposed,  completely  abolished, 
although  the  motion  which  it  really  has  is  extremely 
slight.  The  operation  of  enucleation  consists  in  re- 
moving the  eyeball  from  Tenon's  capsule.  Xow,  the 
external  muscles  of  the  eye,  in  their  course  from  their 
origin  to  their  insertion  on  the  globe,  cross  over  to 
Tenon's  capsule,  and  have  to  penetrate  it  in  order  to 
reach  the  sclerotica.  Bnt,  at  the  very  places  where 
this  penetration  occurs,  the  tendons  of  the  muscles 
become  firmly  united  to  the  capsule.  The  investing 
membrane  of  the  vacant  orbit  is  chiefly  composed  of 
the  conjunctiva  of  the  eyeball,  which  now  covers 
the  capsule  of  Tenon ;  the  latter  in  turn  grasps  the 
muscles  firmly  at  the  fissures  through  which  they 


THERAPEUTICS.  151 

originally  passed.  Now,  if  the  remaining  eye  moves, 
the  corresponding  muscles  on  the  enucleated  side  also 
contract,  so  that  some  slight  movements  are  still 
noticeable  in  the  lining  membrane  of  the  empty  orbit. 
These,  then,  are  the  motions  which  are  partly  trans- 
ferred to  the  artificial  eye,  which  is  held  firmly  against 
Tenon's  capsule  by  the  pressure  of  the  eyelids. 

Although  this  tends  to  show  that  complete  enuclea- 
tion  renders  it  impossible  for  us  so  well  to  satisfy  the 
demands  of  good  looks  as  in  the  case  of  a  stump  which 
still  remains  in  situ,  we  must  nevertheless  remark 
that  this  circumstance  is  of  but  little  importance  in 
the  particular  series  of  cases  with  which  we  now  have 
to  deal.  For,  if  we  have  the  slightest  dread  of  sym- 
pathetic irritation  or  inflammation  in  the  well  eye, 
we  shall  never  dare  to  place  an  artificial  eye  upon  a 
stump  which  is  more  or  less  painful ;  and  even  if  we 
should  by  any  means  succeed  in  entirely  freeing  the 
eye  from  pain  and  irritation,  we  could  never  be  sure 
of  being  able  to  apply  the  artificial  eye  directly  upon 
the  stump  without  the  possibility  of  exciting  sympa- 
thetic symptoms.  Again,  so  long  as  the  dangerous 
eye  has  a  cornea,  as  may  often  happen,  an  artificial 
eye  cannot  well  be  worn ;  and  besides,  if  the  atrophic 
eyeball  has  not  diminished  considerably  in  size,  the 
glass  shell  cannot  be  used. 

Now,  this  cry    of  "  mutilation "   which    has   been 
raised  by  the  opponents  of  too  frequent  enucleation, 


152  SYMPATHETIC   DISEASES    OF   THE   EYE. 

or  of  enucleation  in  general,  cannot  be  accepted  with- 
out a  few  words  of  explanation,  for  the  early  insertion 
of  unbreakable  artificial  eyes  may  greatly  compensate, 
in  the  case  of  a  child,  for  the  disadvantages  of  a  va- 
cant orbit,  accompanied  with  a  deformity  of  the  face, 
or,  more  correctly  speaking,  for  the  inequality  of  de* 
velopment  in  one  orbit  and  half  of  the  face,  in  com- 
parison with  the  other  side.  And,  on  the  other  hand, 
we  must  not  forget  that  a  minute  stump  will  permit  the 
very  same  aspect  of  things  that  we  dread  so  much  in 
the  case  of  an  entirely  empty  orbit.  Thus,  I  have  re- 
peatedly seen  so  small  a  stump  after  blennorrhoea  in 
the  eyes  of  infants,  that  I  was  sure  enucleation  had 
been  performed,  and  only  after  positive  assurances  to 
the  contrary,  was  I  able  to  discover  in  the  bottom  of 
the  orbit  a  stump  about  as  large  as  a  pea,  the  con- 
vexity of  which  could  not  be  seen,  but  only  felt, 
beneath  the  enveloping  conjunctiva.  It  is  therefore  a 
matter  of  no  account  whether  a  stump  of  such  a  size, 
or  even  somewhat  larger,  lies  at  the  bottom  of  the 
orbit  or  not. 

Death,  cellular  inflammation  of  the  orbit,  and  a 
staring  cavity  (as  well  as  other  disadvantages  of  enu- 
cleation, such  as  excess  of  tears,  and  inversion  of  the  lids, 
accompanied  with  irritation  of  the  mucous  membrane 
by  the  eye-lashes),  have  no  direct  relation  to  enucleation 
for  sympathetic  ophthalmia,  but  only  to  enucleation 
generally.  The  most  important  and  most  interesting 


THERAPEUTICS.  153 

question  for  us  is  whether  enucleation  in  and  by  itself 
can  do  any  harm  ;  that  is  to  say,  can  it  endanger  the 
other  healthy  eye  by  producing  sympathetic  irritation  ; 
or  by  increasing  a  slight  form  of  sympathetic  inflam- 
mation already  present,  to  a  more  violent,  or  even  the 
most  violent  form  of  all  ? 

We  have  previously  alluded  to  preventive  ennclea- 
tion  in  those  cases  in  which  the  sympathetic  affec- 
tion appeared  so  quickly  after  the  operation,  that  we 
could  not  but  admit  the  possibility  that  the  inflam- 
mation was  already  under  way  when  the  operation 
was  performed.  In  such  cases  we  can  only  say  that 
the  enucleation,  at  the  most,  hastened  the  sympathy, 
but  did  not  really  produce  it.  But  the  affair  is  quite 
different  in  those  cases  in  which  weeks  or  months 
elapse  after  enucleation)  before  the  sympathetic  symp- 
toms appear.  Thus,  for  example,  enucleation  was  the 
starting-point  of  sympathetic  neuro-retinitis  in  the  two 
cases  of  Mooren's  previously  me  ntioned  (pages  94, 132) ; 
it  also  caused  a  sympathetic  "  hyperaesthesia  ciliaris  " 
in  a  third  case  of  Mooren's,  in  which  the  enucleation 
of  an  eye  destroyed  by  a  gunshot-wound  had  been 
long  before  performed.  "  The  starting-point  of  the 
irritation  in  the  present  case  must  be  sought  for  in 
the  inflamed  end  of  the  optic  nerve  of  the  enucleated 
eye." 

It  seems  to  me,  however,  that  we  have  much  more 

important  facts  in  those  which  tend  to  show  that  enu- 

7* 


154  SYMPATHETIC   DISEASES   OF   THE   EYE. 

cleation  may  increase  those  insignificant  types  of 
sympathetic  affection  which  would  never  have  greatly 
endangered  the  eye,  to  the  most  violent  forms  of 
sympathetic  inflammation.  --Mooren  (1869)  enucleated 
an  eye  affected  with  cyclitis,  because  the  premonitory 
symptoms  of  iritis  serosa — "  there  were  merely  a  few- 
dots  on  the  posterior  wall  of  the  cornea" — had  ap- 
peared in  the  other  eye.  In  the  fifth  week  after  the 
enucleation,  Mooren  for  reasons  unknown  to  us,  made 
an  iridectomy  on  the  remaining  eye,  which  was  still  free 
from  pain.  All  went  well  for  a  time,  but  three 
weeks  later — two  months  in  all  after  the  enncleation — 
a  new  and  intense  inflammation  appeared,  developed 
finally  into  a  genuine  plastic  irido- cyclitis,  and  de- 
stroyed the  eye. 

flasket  Derby  (1874)  enucleated  the  eye  of  a  youn^ 
man  with  vision  of  ^  normal,  because  three  months 
after  an  injury  the  other  showed  simple  iritis  serosa 
(fine  precipitates  on  the  posterior  wall  of  the  cornea 
and  slight  dimness  of  vision).  The  deposits  disappeared 
after  the  enucleation,  and  the  eye,  with  normal  vision, 
became  again  fit  for  work.  But  two  months  later 
irido-cyclitis  appeared.  Derby,  suspecting  irritation  of 
the  stump  of  the  nerve  in  the  region  of  the  cicatrix, 
excised  a  quarter  of  an  inch  of  the  nerve,  with  its  sur- 
rounding tissue.  Improvement  again  followed,  but  did 
not  last  long.  After  several  months,  repeated  attacks 
of  iritis,  combined  with  opacities  in  the  vitreous,  had 


THERAPEUTICS.  155 

reduced  vision  to  ^  normal.  The  final  result  must 
have  been  very  sad. 

Alt  (1877)  described  the  condition  of  an  eye  (in  the 
case  of  a  boy,  aged  nine  years,  injured  seven  years 
before  by  a  needle)  which  was  enucleated  by  Knapp 
for  sympathetic  iritis  serosa.  The  behavior  of  the 
case  after  euucleation  is  interesting.  The  iritis  serosa 
disappeared  rapidly,  but  a  plastic  irido-choroiditis  soon 
developed;  vision  sank  to  T^¥,  then  increased  to  ^s. 
The  termination  of  the  case  was  unknown. 

This  transformation  of  simple  iritis  serosa  into  gen- 
uine irido-cyclitis  after  enucleation,  is  an  extremely 
suspicious  event.  We  have  already  drawn  repeated 
attention  (page  81)  to  the  fact  that  iriti*  serosa,  if  not 
treated  too  heroically,  does  not  seem  to  have  any 
tendency  to  develop  into  the  more  severe  forms  of 
iritis,  and  I  must  confess  that  I  cannot  understand 
how  Mooren  (and  others  after  him)  can  cite  this 
case  of  his,  as  just  quoted,  as  an  argument  against 
the  opinion  of  v.  Graefe  and  Bonders,  that  iritis 
serosa  never  develops  into  iritis  maligua  under  ordi- 
nary circumstances.  Leaving  entirely  aside  the  fact 
that,  in  Mooren 's  case,  an  operation  (iridectomy)  was 
performed  in  the  eye  affected  with  iritis  serosa,  the 
ominous  interval  of  two  months  between  the  enuclea-^ 
tion  and  the  violent  inflammation,  gives  us  a  suffi- 
ciently distinct  indication,  not  that  the  iritis  serosa 
spontaneously  increased  to  iritis  maligna,  but  that  the 


156  SYMPATHETIC   DISEASES    OF   THE    EYE. 

latter  vras  caused  by  the  enncleation  (and  would,  per- 
haps, have  appeared  in  precisely  the  same  manner, 
even  if  the  second  eye,  up  to  that  time,  had  never 
been  operated  upon). 

We  see  the  same  state  of  things  in  Derby's,  Alt's, 
and  in  many  other  cases,  in  which  enncleation  in 
iritis  serosa  has  been  "fruitless" — that  is  to  say,  in 
which  the  second  eye  has  been  destroyed  by  plastic 
irido-cyclitis  after  enncleation  of  the  first. 

Samelsohn's  case  offers  us  a  very  instructive  con- 
trast to  that  of  Derby,  who,  animated  as  he  was  with 
the  best  intentions,  and  guided  by  the  opinions  then 
prevalent,  sacrificed  an  eye  which  still  possessed  vision, 
in  order  to  sa*e  its  partner,  but  lost  both  of  the  eyes ; 
while,  if  he  had  not  operated  at  all,  both  eyes  might 
possibly  have  been  saved.  In  Samelsohn's  case,  which 
is  very  similar  to  those  just  referred  to,  both  eyes  were 
really  saved ;  not,  however,  by  the  skill  of  the  sur- 
geon, but  by  the  persistent  refusal  of  the  relatives  of 
the  patient  to  have  the  proposed  operation  performed. 
We  need  hardly  say,  at  this  point,  that  we  do  not  in- 
tend, in  the  slightest  degree,  to  reproach  the  surgeons 
in  question,  but  simply  to  utter  our  condemnation  of 
those  axioms  according  to  which  enncleation  must  be 
performed  under  such  and  such  circumstances. 

Here  is  Samelsohn's  case  in  brief  (compare  Knapp's 
Archives  of  Ophthalmology  and  Otology,  vol.  v., 
p.  48):  A  boy  of  fourteen  injures  his  left  eye  by  a 


THERAPEUTICS.  157 

blow  from  the  rebound  of  an  elastic  cord.  Six  weeks 
later  fine  dotted  opacities  appear  on  the  posterior  wall 
of  the  cornea,  and,  subsequently,  a  few  delicate  adhe- 
sions are  noticed  at  the  border  of  the  pupil.  The  in- 
jured eye  shortly  before  the  last  inflammatory  attack 
could  still  read  large  letters  (Jaeger,  No.  23)  with  an 
excentric  portion  of  the  field  of  vision ;  finally,  only 
fingers  can  with  difficulty  be  counted.  When  the  last 
attack  in  the  left  eye  begins  to  decrease  in  intensity, 
the  first  symptoms  of  pericorueal  injection,  together 
with  the  characteristic  opacities  on  Descemet's  mem- 
brane, are  noticed  in  the  right  eye.  Enucleation  of 
the  left  eye  is  now  proposed,  but  energetically  refused 
by  the  friends  of  the  patient.  Six  weeks  after  the 
first  appearance  of  the  serous  iritis,  both  eyes  are  not 
only  free  from  inflammation,  but  from  the  least  signs 
of  irritation.  The  eye  which  had  been  affected  by 
sympathy  is  perfectly  normal.  The  injured  eye  has  4 
of  normal  vision,  and  shows  only  a  slight  contraction 
of  the  visual  field. 

In  my  opinion,  there  cannot  be  the  least  doubt  that 
iritis  serosa  may  become  transformed  into  iritis  maligna 
by  the  operation  of  enucleating  the  other  eye.  But,  even 
as  regards  a  slight  attack  of  iritis  plastica,  enuclea- 
tion  cannot,  under  certain  circumstances,  be  wholly  ac- 
quitted of  blame  in  furthering  the  transformation  of 
the  plastic  into  the  malignant  form  of  iritis.  We  must, 
however,  make  a  separation  between  serous  and  plastic 


158  SYMPATHETIC   DISEASES    OF    THE    EYE. 

iritis.  For,  when  we  find  a  few  adhesions  in  the  second 
eye,  before  euucleation,  while  plastic  irido-cyclitis  de- 
velops itself  afterward,  we  can  say,  with  incomparably 
greater  justification  than  if  the  case  had  been  one  of 
iritis  serosa,  that  the  posterior  adhesions  did  indeed 
indicate  the  beginning  of  plastic  irido-cyclitis,  but 
that  emicleation  was  simply  unable  to  retard  the  pro- 
cess. We  may  be  justified,  moreover,  in  saying  that  the 
operation  did  not  exercise  any  unfavorable  influence. 
This  is  undeniably  correct  in  some  cases,  but  not  in 
all.  For  we  frequently  observe  cases  in  which  the 
iritic  process  increases  to  irido-cyclitis  at  such  an  in- 
terval after  the  enucleation,  that  there  can  be  no 
doubt  that  the  plastic  iritis,  if  left  to  itself,  would 
have  passed  off  as  a  mild  attack,  whereas  the  enuclea- 
tion  excited  it  to  irido-cyclitis.  We  will  here  insert 
an  appropriate  case  from  Viguaux's  rich  experience : 
The  eye  causing  the  sympathy  is  blind,  but  entirely 
free  from  pain ;  the  eye  affected  by  sympathy  is 
spontaneously  painful,  as  well  as  painful  to  the  touch 
over  the  ciliary  region,  and  is  affected  with  iritis  ac- 
companied with  slight  adhesions  at  the  lower  edge  of 
the  pupil.  Yision  is  ^  normal.  With  the  help  of 
atropia  the  iritis  disappears  after  the  emicleation.  A 
month  later,  vision  is  fully  i  normal.  Two  months 
after  the  enucleation  a  terrible  inflammation  'appears 
in  the  eye,  and,  after  persisting  for  ten  months,  leaves 
the  organ  in  an  incurable  state  of  total  blindness. 


THERAPEUTICS.  159 

We  have  now  uttered  the  paramount  condemna- 
tory opinion  against  enucleation — i.e.,  that  it  may 
cause  sympathetic  inflammation  in  a  previously  healthy 
eye,  as  well  as  increase  a  mild  inflammation  to  the 
most  ^evere ;  or,  more  correctly  speaking,  that  it  may 
frustrate  the  permanent  cure  of  a  slight  inflammation, 
by  causing  one  of  the  most  severe  type.  Hence,  it  is 
really  only  of  secondary  importance  for  us  to  add  that, 
after  the  outbreak  of  a  genuine  iritis  maligna,  enuclea- 
tio'n  is  not  only  of  no  benefit  whatever,  but  that  occa- 
sionally, when  the  sympathizing  eye  is  extremely  irri- 
tated, it  really  does  harm ;  it  even  accelerates  the 
disastrous  process.  Those  cases  of  genuine  iritis 
maligna  which  have  recovered  after  enucleation,  prove 
nothing  at  all  in  favor  of  the  curative  agency  of  enu- 
cleation, for  no  one  will  dare  to  say  that  in  these  ex- 
traordinarily exceptional  cases,  the  process  would  not 
have  proceeded  in  a  possibly  favorable  manner  even 
without  enucleation,  to  say  nothing  of  the  fact  that 
many  such  cases  of  perfect  recovery  rest  upon  an 
error  in  diagnosis :  the  case  was  riot  a  genuine  plastic 
irido-choroiditis. 

Now  that  we  have  thus  learned  the  disadvantages 
attached  to  enucleation,  and  the  dangers  which  it  may 
possibly  have  in  store  for  the  patient,  it  will  be  much 
easier  for*us  to  decide  upon  the  importance  of  enu- 
cleation in  the  therapeutics  of  sympathetic  affections 
of  the  eye. 


160  SYMPATHETIC   DISEASES  %  OF   THE   EYE. 

The  fatal  results  of  eunclcation  do  not  trouble  us 
much  when  we  are  deciding  upon  the  operation,  for 
the  cases  of  subsequent  death  are  altogether  too  rare. 
But,  under  certain  circumstances,  we  still  have  some 
reserve  in  this  respect.  Almost  all  the  German*  ocu- 
lists hesitate  to  enucleate  during  the  height  of  fla- 
grant panophthalmitis,  standing  as  they  still  do  in 
dread  of  v.  Graefe's  two  fatal  cases  (1863).  This  feel- 
ing goes  so  far,  that  a  German  operator  even  excused 
himself  for  having  enucleated  two  panophthalmitic 
eyes  with  the  best  results,  because  he  did  not  know  at 
the  time  what  v.  Graefe  had  said  on  this  point.  Per- 
sonally, I  stand  in  awe  of  v.  Graefe's  advice  never  to 
operate  if  the  panophthalmitis  is  distinctly  pronounced. 
1  have  never  enucleated  an  eye  under  such  circum- 
stances, and  I  doubt  if  I  shall  ever  make  up  my  mind 
to  do  so.  The  terrible  apparition  in  v.  Graefe's  cases 
impresses  me  so  deeply,  that  at  the  very  sight  of  any 
eye  in  a  state  of  panophthalmitis,  and  the  thought  of 
enucleating  it,  the  dread  of  a  fatal  result  is  conjured 
up  before  me.  By  this,  I  do  not  mean  to  say  that  it 
is  entirely  justifiable  for  us  to  abstain  from  the  opera- 
tion, for  the  English  oculists  never  pay  any  great  at- 
tention to  panophthalmitis  when  they  desire  to  enucle- 
ate. Thus  Critchett  (of  whom,  as  he  himself  laugh- 
ingly said,  the  story  goes  that  he  cannot  go  to  bed 
without  having  enucleated  at  least  one  eye  during  the 
day)  told  me  that  he  had  never  seen  an  accident  under 


THERAPEUTICS.  161 

the  above  circumstances.  Yignaux  also  praises  enucle- 
ation  when  thus  performed  ;  still  he  lost  one  case  out 
of  nineteen,  although  we  must  consider  the  great  age 
(eighty-one)  of  the  patient  in  this  fatal  case. 

We  do  not  mean  in  this  place  to  treat  of  the  general 
indications  and  centra-indications  of  enucleation,  bat 
only  of  enucleation  as  a  therapeutical  resource  in 
sympathetic  affections  of  the  eye.  Hence,  we  must 
justify  ourselves  for  discussing  enucleation  in  panoph- 
thalmitis.  "We  have  here  brought  up  the  subject,  be- 
cause, in  our  opinion,  panophthalmitis  cannot  be  wholly 
acquitted  of  the  fault  of  producing  sympathetic  symp- 
toms (although  it  is  generally  assumed  to  be  innocent, 
on  the  ground  that  the  acute  purulent  inflammation 
entirely  destroys  all  the  nerves  in  the  interior  of  the  eye). 
On  the  contrary,  we  are  sure,  that  flagrant  panophthal- 
mitis may  sometimes  induce  sympathetic  inflammation, 
so  that  a  few  weeks  after  the  outbreak  of  the  original 
disease,  and  even  at  the  time  when  it  has  by  no  means 
entirely  disappeared,  the  premonitory  symptoms  of 
sympathy  may  reveal  themselves  in  the  other  eye. 
Moreover,  we  mention  enucleation  in  this  place  be- 
cause when  the  panophthalmitis  is  excited  by  the  pres- 
ence of  a  foreign  body  remaining  in  the  eye,  we  can- 
not expect  a  permanent  condition  of  rest  in  the 
atrophic  eyeball,  even  after  the  process  has  ended,  but 
on  the  contrary,  permanent  or  occasional  spontaneous 
pain,  or  pain  upon  pressure,  as  well  as  the  over-threat- 


162  SYMPATHETIC   DISEASES    OF   THE   EYE. 

ening  danger  of  sympathetic  ophthalmia.  So,  if  we 
venture  to  enucleate  during  the  stage  of  panophthal- 
mitis,  we  may  not  only  put  an  end  to  the  sufferings  of 
the  patient,  produced  by  the  acute  inflammation,  but 
secure  him  from  the  danger  of  sympathetic  disease  in 
the  other  eye  for  the  rest  of  his  life.  But  if  any  one 
is  restrained  from  the  enucleation  of  a  panophthal- 
initic  eye  by  the  dread  of  a  fatal  result,  the  reasons 
which  we  have  just  suggested  in  favor  of  enucleation 
daring  this  period,  will  not  be  urgent  enough  to  over- 
come his  fears.  For  the  appearance  of  sympathetic 
ophthalmia  during  flagrant  panophthalmitis,  although 
observed  by  a  few  oculists,  is  so  extremely  rare  as  not 
to  offer  any  general  indications  for  the  operation.  In 
case,  therefore,  that  the  enucleation  of  the  eye  appears 
desirable  as  a  precaution  against  sympathy  in  the  fu- 
ture, we  can  wait  until  the  panophthalmitis  lias  grad- 
ually diminished  under  suitable  treatment — in  case  we 
did  not  prefer  to  enucleate,  or  could  not  enucleate  di- 
rectly after  the  injury  and  previously  to  the  appear- 
ance of  the  panophthalmitis. 

Experience  teaches  us  that  when  the  irritation  of  the 
nerves  has  not  yet  extended  to  their  extra-ocular 
branches,  it  is  one  of  the  rarest  of  exceptions  for  enu- 
cleation to  lead  to  dangerous  irritation  in  these  latter 
filaments  ;  and  that  whenever  this  does  occur,  the  im- 
perfect execution  of  the  operation,  or  the  crushing  of 
the  nerves  during  their  division,  is  directly  to  blame  in 


THERAPEUTICS.  163 

a  considerable  portion  of  the  cases.  "We  have,  more- 
over, for  the  purpose  of  tabulation;  only  a  very  small 
number  of  cases  in  which  we  can  say  that  the  operator 
unwittingly  caused  the  stump  of  the  optic  nerve  con- 
cerned to  become  constringed  in  the  cicatrix.  From 
all  these  remarks  we  see  that  there  is  but  slight  proba- 
bility of  an  intact  second  eye  being  endangered  by 
enucleation  of  the  first.  And  finally,  so  long  as  it 
has  not  been  satisfactorily  demonstrated,  in  any  great 
number  of  cases,  that  enucleation  increases  a  con- 
dition of  simple  irritation  or  mere  disturbance  of  func- 
tion to  distinct  inflammation,  then,  from  this  point  of 
view  also,  enucleation  is,  on  the  whole,  by  no  means  to 
be  dreaded. 

To  sum  up  our  remarks,  we  have  the  following  in- 
dications and  contra-indications  for  enucleation. 

If  the  second  eye  is  still  perfectly  normal,  oculists 
generally  have  not,  up  to  this  time,  agreed  upon  the 
point  whether  preventive  enucleation  is  admissible. 
My  rule  in  such  cases  is  «as  follows  :  if  the  patient 
is  moderately  intelligent,  has  good  surroundings  at 
his  home,  and  can  at  any  moment  summon  the 
counsel  of  a  skilful  oculist,  preventive  enucleation 
is  not  necessary.  Some  ophthalmologists  claim  that 
sympathetic  inflammation  can  appear  suddenly,  and 
without  any  warning ;  but  such  is  not  my  belief. 
The  intelligent  patient,  warned  of  the  threatening 
danger  and  notified  to  appear  at  once  upon  the 


164  SYMPATHETIC   DISEASES   OF   THE   EYE. 

slightest  disturbance  on  the  part  of  the  sound  eye, 
will  hardly  come  to  us  with  a  pronounced  irido-cycli- 
tis,  but  at  the  first  appearance  of  the  slightest  symp- 
tom of  irritation.  If,  on  the  other  hand,  we  have 
before  us  one  of  the  lower  classes,  a  patient  defective 
in  intelligence  and  in  whom  carelessness  and  mistrust 
of  medical  assistance  are  narrowly  united  ;  one  whose 
remaining  eye  is  liable  to  be  overburdened  with  severe 
labor,  and  who  cannot,  even  with  the  best  intentions, 
get  the  advice  of  an  oculist ;  then  we  may  employ 
all  our  eloquence  in  favor  of  a  preventive  enucleation. 
For,  notwithstanding  our  most  earnest  warnings,  as  well 
as  all  our  representations  that  the  patient  will  be  totally 
blind  for  life  if  he  neglects  to  report  at  the  proper 
moment — despite  all  sorts  of  promises  on  the  part 
of  the  patient  that  he  will  seek  advice  when  the  slight- 
est irritation  appears,  we  may  never  see  such  a  patient 
again  until  vision  shall  have  been  irrevocably  de- 
stroyed by  a  genuine  attack  of  irido-cyclitis.  Of  what 
avail,  then,  to  overwhelm  t^e  unfortunate  patient  with 
reproaches,  to  remind  him  of  his  promises,  and  even 
to  fly  into  a  passion,  or  to  melt  into  pity,  when  he 
mildly  says  that  he  thought  the  eye  would  get  well  of 
itself,  or  that  he  sought  help  at  the  hands  of  some  old 
woman ! 

The  fact  that  the  eye  which  is  liable  to  cause  sym- 
pathetic diseases  at  some  future  time  still  possesses  a 
certain  amount  of  vision,  never  contra-indicates  the 


THERAPEUTICS.  165 

performance  of  PREVENTIVE  enucleation.  Those  who 
resort  to  preventive  enucleation  on  principle,  or  who 
regard  it  as  a  necessary  duty  to  advise  the  enucleation  of 
an  eye  in  any  special  case,  should  never  let  themselves 
be  led  astray  by  the  circumstance  that  the  injured  or 
irritated  organ  still  possesses  some  remnant  of  vision. 
The  enucleation  of  an  eye  which  still  possesses  the 
faculty  of  sight,  or  one  in  which  some  degree  of  vision 
might  possibly  be  restored  at  a  later  date,  may  be  an 
unjustifiable  deed  in  the  general  province  of  ophthal- 
mology, but  it  can  never  serve  as  an  argument  in  favor 
of  abandoning  preventive  enucleation.  For  the  removal 
of  this  eye  assures  the  safety  of  the  other,  and  no  one 
should  fear  any  subsequent  objection  to  the  operation. 
But  frightful  must  be  the  silent  accusation  of  one's 
conscience,  when  the  patient  in  whom  we  regarded 
preventive  enucleation  as  a  necessity,  but  in  whose 
case  we  were  so  weak  as  to  be  false  to  our  convictions 
(simply  because  he  still  retained  some  vision  in  the  in- 
jured eye),  reappears  before  us  with  both  eyes  irre- 
trievably lost.  Read,  for  example,  this  case  of  Vig- 
naux's :  "  A  child  about  ten  years  old  has  received  a 
blow  on  one  of  his  eyes.  Gayet  is  of  the  opinion  that 
the  eye  should  be  enucleated,  but  abandons  the  opera- 
tion because  the  eye  still  possesses  a  certain  amount  of 
perception  of  light,  and  it  is  very  hard  to  deprive  such 
a  young  person  of  an  eye  which  still  offers  some  hopes 
for  recovery  of  sight.  After  a  short  time  the  child  re- 


166  SYMPATHETIC   DISEASES   OF   THE   EYE. 

turns  with  the  fully  developed  symptoms  of  sympa- 
thetic inflammation.  The  injured  eye  is  enucleated  ; 
but  it  is  too  late;  blindness  becomes  total."  Gayet 
recalls  this  case  to  mind  two  years  later,  and  says :  "  I 
shall  regret  this  during  the  whole  of  my  life."  And  I 
add,  we  hope  that  at  the  time  when  enucleatiori  was 
finally  performed,  vision  was  really  wholly  lost  in  the 
injured  eye,  for  if  it  were  not,  Gayet  added  to  his 
previous  error  of  abandoning  preventive  enucleation 
(one,  by  the  way,  in  which,  on  account  of  the  prevalent 
di&'erence  of  opinions,  he  might  find  easy  absolution) 
a  second  more  grievous  and  much  less  excusable  error, 
as  shall  soon  be  dilated  upon  more  fully. 

While  discussing  this  point,  I  would  like  to  add 
that  I  cannot  see  how  Yignaux,  while  still  depressed 
in  mind  by  this  case  of  Gayet's,  could  make  such  a 
remark  as  the  following,  one  of  the  chief  reasons 
against  preventive  enucleation  :  "  Preventive  enuclea- 
tion is  generally  contra-indicated  in  case  the  second 
eye  exhibits  perfect  organic  and  functional  integrity, 
and  the  originally  injured  eye  still  retains  a  certain 
amount  of  sight,  or  could  obtain  useful  vision  by 
operative  interference  at  a  later  date." 

If  the  general  symptoms  of  sympathetic  irritation 
are  already  present,  enucleation  must  be  performed 
at  once.  For,  although  cases  have  been  known  in 
which  sympathetic  irritation  of  the  eye  has  lasted  for 
years,  and  even  decades,  without  really  endangering 


THERAPEUTICS.  167 

vision,  yet  the  physician  cannot  rely  upon  such  a 
rare  possibility  in  his  own  special  case,  in  thinking 
over  what  remedy  he  shall  employ.  He  must,  on  the 
contrary,  regard  the  irritative  symptoms  as  premoni- 
tory of  the  sympathetic  inflammation,  and,  keeping  in 
mind  the  danger  that  irido-cyclitis  may  be  developed 
in  a  few  weeks,  even  if  no  organic  alterations  are  as 
yet  present,  he  must  decline  all  responsibility  in  the 
case,  if  enucleation  is  proposed  to  the  patient,  but  re- 
fused. The  oculist  may  act  under  such  circumstances 
with,  energy  and  confidence  ;  for,  notwithstanding  the 
few  exceptional  cases  in  which  the  inflammatory  pro- 
cess is  already  under  way,  even  here  enucleation  gen- 
erally acts  safely. 

When  the  other  eye  is  in  a  state  of  irritation,  an 
eye  which  still  possesses  vision  must  be  unhesitatingly 
sacrificed :  success  is  too  certain,  and  too  much  is  at 
stake,  for  the  oculist  to  hesitate.  If,  in  such  a  case,  he 
meets  the  rare  misfortune  of  seeing  the  irritation  be- 
come developed  into  inflammation  despite  the  enu- 
cleation, he  can  say  with  confidence :  "  All  is  lost, 
but  not  my  peace  of  mind."  The  surgeon  cannot  act 
differently,  and  such  a  tragic  accident  as  just  sug- 
gested is  so  rare  that  the  vast  majority  of  operators 
pass  through  life  without  meeting  with  such  a  lament- 
able experience. 

If  iritis  serosa,  and  iritis  serosa  alone,  is  already 
present  in  the  second  eye,  enucleation  is,  in  my  opinion, 


168  SYMPATHETIC   DISEASES    OF   THE    EYE. 

contra-indicated  ;  and  the  enucleation,  under  these  cir- 
cumstances, of  an  eye  which  is  not  totally  blind,  is  ab- 
solutely unjustifiable.  I  shall  never  again  perform 
enucleation  for  sympathetic  iritis  serosa,  for,  as  on  the 
one  hand  this  form  of  inflammation  never  shows  any 
tendency  to  develop  into  irido-cyclitis,  so,  on  the 
other,  we  have  already  offered  proof  of  the  deleterious 
influence  of  operative  interference  during  the  pres- 
ence of  this  disease.  In  such  cases,  in  all  probability, 
enucleation  does  more  harm  than  good  to  the  second 
eye.  Nor  could  I  decide  to  enucleate  in  a  case 
of  simple  plastic  iritis  with  a  few  adhesions,  or 
even  with  adhesions  entirely  around  the  margin  of 
the  pupil.  We  see  a  case  like  Vignaux's  (page  158) 
in  the  one  reported  by  Hirschberg  (1874),  in  which 
enucleation  was  performed  within  a  few  hours  after 
the  outbreak  of  a  simple  plastic  iritis  in  the  second 
eye.  The  iritis  proceeded  favorably,  but,  about  three 
weeJes  after  the  enucleation,  a  relapse  occurred  and 
the  eye  was  finally  lost.  Even  if  Hirschberg  is  cor- 
rect in  assuming  that  the  enucleation  in  this  case  was 
simply  incapable  of  cutting  short  the  irido-cyclitis 
which  was  already  under  way,  the  inexpediency  of  the 
operation  would  be  evident.  Under  such  circumstan- 
ces enucleation  cannot  be  of  any  advantage;  it  can 
only  do  harm.  But  we  have  already  explained  that 
plastic  iritis  is  far  from  being  synonymous  with  the 
primary  stage  of  irido-cyclitis.  For  other  reasons, 


THERAPEUTICS.  169 

however,  a  similar  case  of  this  sort  will  be  mentioned 
farther  on. 

Inasmuch  as  enucleation  undertaken  during  a  vio- 
lent inflammatory  condition  of  the  first  eye  is  of  no 
benefit  in  the  presence  of  sympathetic  irido-cyclitis  ^ 
and  may  even  rapidly  increase  the  pernicious  inflam- 
mation, it  follows  that,  when  we  still  desire  to  enu- 
cleate, we  should  wait  until  the  inflammatory  process 
in  the  eye  which  has  been  first  affected  begins  to  show 
some  relative  pause.  There  is  no  general  indication 
for  enucleation  in  cases  of  sympathetic  irido-cyclitis. 
If,  notwithstanding  this,  the  eye  is  enucleated  in  this 
stage,  the  main  idea  can  only  be  that  where  all  is  ir- 
redeemably lost,  there  is  nothing  more  to  lose.  Every 
one  will  admit  that  it  is  a  crime  in  a  case  of  pro- 
nounced sympathetic  irido-cyclitis •,  to  enucleate  an  eye 
which  still  possesses  vision,  or  in  which  vision  might 
at  a  later  date  be  restored.  It  ought  to  be  absolutely 
impossible  for  any  oculist  to  have  the  opportunity  of 
congratulating  himself,  at  the  refusal  of  the  proposed 
enucleation  of  an  eye  which  still  possesses  vision  while 
the  other  eye  is  affected  with  sympathetic  irido-cycli- 
tis ;  because  the  omission  of  enucleation  under  such 
circumstances  should  never  be  due  to  a  lucky  chance, 
but  be  dictated  by  the  sagacity  of  the  surgeon  in 
charge  of  the  case.  Every  one  ought  to  know,  and 
must  know  in  such  a  case  that  enucleation  cannot 
be  of  any  avail.  The  oculist  ought  to  know,  even 


170  SYMPATHETIC   DISEASES   OF   THE   EYE. 

if  there  are  several  well-known  cases  in  which  irido- 
cyclitis  has  not  led  to  total  blindness  after  enuclea- 
tion,  that  this  favorable  result  was  not  obtained  by 
the  enucleation,  but  despite  it.  Moreover,  he  should 
be  aware,  on  the  other  hand,  that  numerous  cases 
have  been  reported,  in  which  the  eye  causing  sympa- 
thy has  saved  the  patient  from  everlasting  darkness, 
for  the  very  reason  that  this  eye  still  retained  some 
useful  vision  after  the  eye  affected  by  sympathy  had 
become  totally  destroyed.  Y.  Graefe  said,  after 
seeing  two  cases  in  which  he  refused  to  enucleate  be- 
cause the  first  eye  was  not  totally  blind  :  "  I  was  ex- 
tremely interested  in  these  cases,  by  seeing  perfect 
recovery  from  the  sympathetic  affection." 

My  creed  in  the  question  of  enucleation  runs 
briefly  thus  :  It  MAY  be  performed  as  a  preventive ; 
it  MUST  be  performed  in  the  stage  of  irritation ;  it 
CANNOT  be  performed  in  iritis  serosa  and  iritis  plas- 
tica ;  it  CAN  be  performed  in  irido-cyclitis  plastica, 
provided  the  eye  causing  sympathy  is  totally  Hind, 
but  not  in  a  state  of  violent  irritation. 

The  most  important  point,  so  far  as  the  general  prac- 
titioner is  concerned,  is  that  he  shall  know  the  indica- 
tions and  contra-indications  for  enucleation.  It  is  a 
matter  of  minor  importance,  whether,  after  having 
made  a  correct  diagnosis,  he  can  himself  perform  the 
operation,  or  feels  obliged  to  refer  the  patient  to  a 
specialist  for  its  performance.  Still,  I  will  in  this 


THERAPEUTICS.  171 

p]ace  describe  the  details  of  the  operation,  as  well  as 
its  after-treatment.  Augustus  Pritchard,  of  Bristol, 
England,  was  the  first  to  enucleate  a  human  eye  for 
sympathetic  ophthalmia  (1851).  The  term  "enuclea- 
tion  "  owes  currency  in  speech  to  v.  Arlt,  who  pro- 
posed to  use  the  term  "  enucleation  of  the  eye  "  instead 
of  "  exeriteration  of  the  orbit ;  "  that  is  to  say,  "  the  re- 
moval of  the  globe  from  Tenon's  capsule,"  in  contra- 
distinction to  the  complete  evacuation  of  the  orbit,  or 
the  removal  of  the  eyeball  with  all  that  lies  behind  it 
in  the  orbit.  Y.  Arlt  reserves  the  expression  "  extir- 
pation "  for  the  removal  of  some  definite  structure,  such 
as  a  new-growth,  from  the  orbit,  with  preservation  of 
the  eyeball.  The  shelling  out  of  the  eye  from  its 
envelope  was  first  proposed  by  Bonnet  (1841),  and  is 
performed  in  the  following  manner  by  v.  Arlt. 

Suppose  that  we  intend  to  enucleate  the  left  eye. 
The  eyelids  are  kept  apart  by  a  stop-speculum,  or,  still 
better,  by  two  lid-elevators  in  the  hands  of  the  assist- 
ant. In  the  latter  case,  by  pushing  the  elevators  along 
the  lid,  the  assistant  can  separate  the  lids  wherever 
the  operator,  for  the  time-being,  requires  the  most 
room.  The  surgeon  seizes  the  conjunctiva  just  over 
the  insertion  of  the  rectus  externus  muscle,  with  the 
forceps,  divides  it  vertically  with  a  pair  of  straight, 
blunt-pointed  scissors,  and  then  continues  the  incision 
in  the  conjunctiva  half-way  around  the  cornea  and 
close  to  its  upper  edge,  until  he  reaches  the  insertion 


172  SYMPATHETIC    DISEASES    OF    THE    EYE. 

of  the  internal  rectus.  He  then  returns  to  the  origi- 
nal opening  in  the  conjunctiva,  and  divides  that  mem- 
brane in  a  similar  manner  all  around  the  lower  margin 
of  the  cornea,  but  leaving  a  bridge  of  conjunctiva  still 
standing  at  the  inner  side  of  the  cornea,  just  over  the 
insertion  of  the  rectus  interims.  The  next  step  con- 
sists in  seizing  the  external  rectus  with  the  forceps, 
and  dividing  it  completely;  not,  however,  between  the 
forceps  and  the  insertion  of  the  muscle  on  the  scle- 
rotica,  but  outside  the  forceps ;  or,  more  plainly  still, 
between  the  forceps  and  the  outer  angle  of  the  eyelids. 
In  this  way  we  have  the  stump  of  a  muscle  still  at- 
tached to  the  eyeball,  so  that  by  seizing  this  with  the 
forceps  we  can  rotate  the  eyeball  in  any  desired  direc- 
tion. One  blade  of  the  scissors  is  now  directed  up- 
ward beneath  the  tendon  of  the  rectus  superior,  so  that 
on  closing  the  scissors  the  tendon  of  this  muscle  is 
completely  divided  from  its  attachment.  After  sever- 
ing the  rectus  superior,  the  rectns  inferior  is  treated  in 
a  similar  manner.  If  we  use  a  common  stop-specu- 
lum, the  assistant,  having  his  hands  free  and  possess- 
ing a  sufficient  degree  of  dexterity,  can  help  the  oper- 
ator a  great  deal  by  taking  up  the  tendons  of  the  vari- 
ous muscles  with  the  common  strabismus-hook,  and 
lifting  them  awa}7  from  the  sclerotica,  so  that  it  takes 
but  an  instant  for  the  surgeon  to  pass  the  blade  of  the 
scissors  between  the  sclerotica  and  the  tendon,  and  to 
divide  the  latter  completely.  An  operator  of  little 


THERAPEUTICS.  173 

skill,  with  an  assistant  of  less  skill,  will  of  course 
help  himself  by  taking  up  one  muscle  after  another 
with  the  hook,  before  dividing  them. 

The  three  recti  muscles  (the  rectus  internus  yet 
stands),  with  the  conjunctiva  which  still  covers  them, 
have  now  been  divided,  or,  more  correctly  speaking, 
the  tendons  of  the  muscles,  as  well  as  the  conjunctiva, 
have  been  loosened  from  the  eyeball.  Now  comes 
the  most  important  step,  the  festal  moment  of  the 
operation — the  division  of  the  optic  nerve. 

The  optic  nerve  is  inserted  into  the  horizontal  plane 
of  the  eye,  but  not  precisely  at  its  posterior  pole  ;  not 
at  the  posterior  end  of  the  antero-posterior  axis  of  the 
eye,  but  a  little  toward  the  nasal  side.  In  order, 
therefore,  to  pass  deeply  into  the  orbit  with  the  scis- 
sors, the  eye  must  be  first  turned  toward  the  nose  by 
means  of  the  stump  of  the  external  rectus.  But  if 
the  eye  rolls  at  all  on  its  antero-posterior  axis,  the  in- 
sertion of  the  optic  nerve  no  longer  lies  in  the  trans- 
verse axis  of  the  eye,  but  approaches  either  the  upper 
or  the  lower  wall  of  the  orbit.  In  order  to  strike  di- 
rectly across  the  optic  nerve  on  introducing  the  scis- 
sors, we  must  be  sure  that  the  optic  nerve  remains  in 
the  transverse  plane  of  the  eye,  which  can  only  hap- 
pen when  we  turn  the  eye  precisely  inward  by  seizing 
the  stump  of  the  external  rectus.  Hence,  we  must  be 
sure  to  notice,  when  turning  the  eye  inward,  whether 
it  rotates  at  all  on  its  antero-posterior  axis.  If  this 


174:  SYMPATHETIC    DISEASES   OF   THE    EYE. 

should  take  place,  we  are  to  move  the  eye  back  again 
to  its  original  position,  and  repeat  the  manoeuvre  until 
the  correct  position  is  reached.  While  the  left  hand  is 
thus  engaged,  the  right  hand  seizes  a  pair  of  strong, 
blunt-pointed  scissors,  curved  on  the  flat,  passes  them 
(still  closed)  a  short  distance  into  the  orbit  along  the 
horizontal  plane  of  the  eye,  opens  them,  so  far  as  is  pos- 
sible without  resistance,  pushes  them  forward,  and 
closes  them  rapidly.  A  certain  resistance  on  closing 
the  scissors,  a  distinct,  grating  sound,  extremely  agree- 
able to  the  ear  of  the  operator  (for  nothing  is  more  dis- 
agreeable, in  the  operation  of  enucleation,  than  to  miss 
the  optic  nerve),  and  the  possibility  of  immediately 
lifting  the  globe  out  from  between  the  eyelids,  show 
that  the  operation  has  succeeded.  But,  if  we  have 
been  so  unlucky  as  to  miss  the  optic  nerve,  we  should 
not  attempt  to  reach  it  by  repeatedly  opening  and 
closing  the  scissors  while  in  the  cavity  of  the  orbit. 
For  the  optic  nerve  now  lies  outside  the  scissors ;  it 
lies  either  above  or  below  the  latter.  We  should 
therefore  remove  the  scissors  entirely,  once  more  care- 
fully rotate  the  eyeball  inward,  and  then  repeat  the 
manoeuvre  with  the  scissors. 

When  the  optic  nerve  has  been  divided,  and  the 
eyeball  drawn  out  from  between  the  eyelids  with  the 
forceps,  we  take  it  in  our  left  hand,  divide  the  inser- 
tions of  both  oblique  muscles,  then  the  rectus  interims, 
next  the  bridge  of  conjunctiva  which  still  stands  at 


THERAPEUTICS.  175 

the  inner  edge  of  the  cornea,  and  the  operation  is 
completed  ;  the  eyeball,  smooth  and  bare  of  all  its  at- 
tachments, with  the  optic  nerve  cut  off  close  to  the 
sclerotica,  lies  in  our  hand. 

If  the  right  eye  is  to  be  enucleated,  we  begin  the 
operation  over  the  insertion  of  the  rectus  iriternus, 
then  divide  the  rectus  superior  and  rectus  inferior, 
leaving  the  bridge  of  conjunctiva  standing  at  the  outer 
side  of  the  cornea.  We  should  also  remember  that,  on 
account  of  the  insertion  of  the  optic  nerve  on  the  nasal 
side  of  the  antero-posterior  axis  of  the  eye,  the  nerve 
is  found  at  a  much  less  depth  when  we  operate  on  the 
right  eye,  than  is  the  case  with  the  left. 

The  hemorrhage  after  the  operation  is  generally 
slight.  We  may  lay  a  couple  of  small  plugs  of  char- 
pie,  cooled  by  contact  with  ice,  into  the  cavity,  apply 
charpie  over  the  closed  lids,  and  over  all  v.  Graefe's 
compress  -  bandage  (three  or  four  turns  of  flannel), 
which  is  to  be  changed  after  twenty-four  hours,  and 
removed  on  the  second  day  after  the  operation.  In 
the  course  of  recovery,  the  capsule  of  Tenon  gradually 
becomes  covered  with  conjunctiva,  and  in  about  a 
week  we  see  at  the  bottom  of  the  orbit  nothing  but  a 
small  suppurating  and  granulating  surface,  which  soon 
cicatrizes  completely. 

The  first  thing  of  which  we  should  be  absolutely 
sure  in  operating  for  sympathetic  ophthalmia  is  to 
enucleate  the  right  eye.  This  may  seem  idle  advice, 


176  SYMPATHETIC   DISEASES    OF   THE   EYE. 

and  even  a  joke ;  but,  whoever  like  myself  has  once 
stood  shudderingly  by,  while  the  eye  which  still  pos- 
sessed vision  was  about  to  be  enucleated  instead  of  the 
blind  eye,  will  not  see  a  jest  in  these  words  of  mine. 
The  error  is  not  inexplicable  when  we  reflect  that 
enucleation  is  frequently  performed  even  when  sym- 
pathetic cyclitis  is  already  fully  developed,  so  that 
there  is  really  no  obvious  difference  between  the  two 
eyes.  Moreover,  the  operator  is  directing  all  his  at- 
tention to  the  operation,  and,  being  willingly  led  by 
the  assistant,  begins  the  operation  on  the  eye  to  which 
the  latter  by  mistake  applies  the  speculum.  The  pa- 
tient makes  no  protest — for  he  is  under  the  influence 
of  anaesthetics. 

Anaesthetics  have  generally  been  resorted  to  in  enu- 
cleation because  the  operation  has  been  considered 
excruciatingly  painful,  especially  during  the  division 
of  the  optic  nerve,  as  well  as  of  the  ciliary  nerves.  I 
had  always  believed  in  this  idea  myself,  and  would 
scarcely  have  dared  to  enucleate  without  anaesthetics, 
had  I  not  been  compelled,  in  the  case  of  a  drunkard 
who  really  could  not  be  chloroformed,  to  operate  upon 
him  in  a  conscious  condition.  I  was  not  a  little 
amazed  when  I  found  that  the  section  of  the  various 
nerves  was  accompanied  with  no  more  acute  expres- 
sions of  pain  on  the  part  of  the  patient  than  during 
the  first  incisions  in  the  conjunctiva.  Since  then  I 
have  repeatedly  enucleated  without  anaesthetics,  and 


THERAPEUTICS.  177 

have  usually  discovered,  on  questioning  the  patients 
after  the  operation,  that  the  first  incision  (in  the  con- 
junctiva) was  more  painful  than  the  division  of  the 
nerves.  Mooren  once  went  so  far  as  to  say  that,  "  in- 
asmuch as  the  operation  is  quickly  performed,  chloro- 
form is  used  only  when  the  patient  expressly  desires 
it ; "  and  again :  "  besides  this,  I  can  operate  much 
more  easily  if  the  patient  is  not  chloroformed."  At 
the  time  when  I  read  these  sentences,  I  was  so  firm  in 
the  belief  that  the  division  of  tho  nerves  was  extremely 
painful,  that  I  could  not  credit  what  Mooren  had  said. 
But  recent  experience  of  my  own  has  shown  me  how 
true  it  all  is. 

Thus  far  for  enucleation.  The  next  question  that 
comes  up  for  our  consideration  is  this  :  Inasmuch  as 
the  whole  significance  of  the  operation  of  enucleation 
depends  upon  the  interruption  which  it  causes  in  the 
conduction  of  irritation  from  the  infra-ocular  nerve- 
fibres  to  the  extra-ocular  branches,  can  we  not  gain 
precisely  the  same  result  by  simply  dividing  the  optic 
nerve  (neurotomy)  ? 

The  history,  in  brief,  of  neurotomy  for  warding  off 
or  curing  sympathetic  ophthalmia  is  as  follows  :  In 
1857,  v.  Graefe  said:  "In  order  to  decide  whether 
the  optic  nerve  takes  an  active  part  in  the  sympathetic 
processes  of  amaurosis,  I  have  proposed  in  similar 
cases  to  substitute  neurotomy  for  extirpation  of  the 

eye.      Under    precisely   analogous   circumstances   we 

8* 


178  SYMPATHETIC   DISEASES    OF   THE   EYE. 

should,  by  adopting  neurotomy,  gain  the  advantage  of 
preserving  the  eye."  In  1865,  Rheindorf  reported  a 
case  of  neurotomy  performed  for  sympathetic  neuro- 
retinitis,  with  scissors  bent  exceedingly  on  the  flat, 
and  rounded  off  at  the  points.  Four  days  later  the 
vision  had  increased  by  four  numbers  of  Jaeger's  test- 
type,  and  the  recovery  was  permanent.  The  influence 
of  the  operation  in  this  case  could  not  be  denied,  for 
the  excessive  diminution  of  vision  had  persisted  for 
months,  during  which  period  all  treatment  had  been 
useless.  The  operated  eye,  at  a  later  date,  showed 
considerable  injection  of  the  anterior  ciliary  veins. 

In  1866,  v.  Graefe  returns  to  the  question  once  more. 
Nine  years  previously  he  had  proposed  to  divide 
the  optic  nerve,  not  as  Mooren  thinks,  because  "  the 
celebrated  suggester  of  this  procedure  meant  also  to 
divide  the  ciliary  nerves,"  but  because  in  these  cases 
it  seemed  to  him  that  the  optic  nerve  served  as  a  con- 
ductor. At  this  time,  however,  it  is  the  section  of  the 
ciliary  nerves  which  v.  Graefe  proposes,  although  he 
doubts  the  propriety  of  dividing  all  of  them  out- 
side the  eye,  "on  account  of  the  necessarily  exten- 
sive denudation,  and  especially  on  account  of  the  si- 
multaneous division  of  the  vessels."  On  the  other 
hand,  in  case  of  circumscribed  sensibility  of  the  ciliary 
nerves,  we  might  divide  such  as  were  implicated,  out- 
side the  eye,  or  perhaps  better  still,  inside  the  eye, 
behind  the  flat  portion  of  the  ciliary  body.  Ed. 


THERAPEUTICS.  179 

Meyer  first  performed  such  an  intra-ocular  division  in 
1866,  and  in  1867  and  1868  he  reported  this  case,  as 
well  as  several  others  in  which  en ucleation  would  have 
been  indicated  as  a  preventive,  or  on  account  of  irri- 
tation already  present.  A  narrow  knife  is  passed 
through  the  sclerotica  into  the  vitreous;  and  a  section 
six  to  eight  lines  long  (depending  upon  the  extent  of 
the  painful  region),  and  parallel  to  the  margin  of  the 
cornea,  is  completed  by  simple  counter-puncture,  and 
division  of  the  overlying  bridge  of  tissues.  In  1868, 
Secondi  also  reported  a  case  of  radical  cure  of  sympa- 
thetic neurosis  by  intra-ocular  ciliary  neurotomy.  All 
the  tunics  of  the  eye  were  completely  divided  over  a 
space  of  a  centimetre  or  two  in  extent,  between  the  in- 
sertion of  the  rectus  externus,  and  that  of  the  rectus 
superior.  Lawrence  also  reported  a  similar  case  in 
1868.  Ed.  Meyer  afterward  continued  to  operate  in 
this  same  manner,  and  in  1873  speaks  of  twenty-two 
cases  of  which  he  has  heard.  He  thinks  that  intra- 
ocular neurotomy  is  really  indicated  as  a  preventive, 
as  well  as  in  cases  of  actual  sympathetic  neurosis. 

In  considering  the  question  of  division  of  the  ciliary 
nerves  outside  the  eye,  we  are  to  distinguish  between 
their  division  with  preservation  of  the  optic  nerve, 
and  the  simultaneous  division  of  both  the  ciliary 
and  optic  nerves.  Snellcn  (1873)  reports  a  success- 
ful division  of  some  of  the  ciliary  nerves  behind 
the  eye  without  doing  any  injury  to  the  optio  nerve. 


180  SYMPATHETIC   DISEASES   OF   THE   EYE. 

The  eye  was  totally  blind,  with  excessive  and  cir- 
cumscribed tenderness  to  pressure  at  the  upper  and 
outer  margin  of  the  cornea.  Y.  Wecker  (Therapeu- 
tique  Oculaire)  recommends  this  operative  method  for 
cases  in  which  the  injured  eye  possesses  better  vision 
than  the  one  sympathetically  affected  whose  vision  is 
totally  lost.  In  his  opinion  we  ought  not  to  enucleate 
under  such  circumstances,  but  we  may  divide  the 
ciliary  nerves  which  surround  the  trunk  of  the  optic 
nerve.  Nevertheless,  it  is  not  plain  from  v.  Wecker's 
account  that  he  ever  really  performed  the  operation. 

The  division  of  both  ciliary  and  optic  nerves  behind 
the  eyeball,  as  a  general  substitute  for  enucleation, 
was  recommended  by  Boucheron  in  1876,  and  subse- 
quently by  Scholer  and  Schweigger.  Scholer  thinks 
that  this  operation  is  entirely  safe  in  all  cases  of  threat- 
ening sympathetic  ophthalmia,  while  Schweigger  is  of 
the  opinion  that  enucleation  is  only  beneficial  as  a  pre- 
ventive operation,  and  that,  from  this  point  of  view, 
neurotomy  is  just  as  available  as  enucleation,  which  in 
his  judgment  has  hitherto  been  opposed  by  the  patient, 
on  account  of  the  dread  "  which  the  mutilation  of  one 
of  man's  noblest  organs "  must  naturally  arouse. 
Finally  Hirschberg,  although  he  once  published  a 
paper  opposing  neurotomy,  subsequently  convinced 
himself,  in  two  cases,  that  it  succeeded  in  relieving 
ciliary  pain. 

I  would  like  in  this  place  to  make  a  few  preliminary 


THERAPEUTICS.  181 

remarks  on  neurotomies  in  general.  It  seems  to  me 
that  it  is  only  a  complete  extra-ocular  division  of  all 
the  ciliary  nerves,  as  well  as  of  the  optic  nerve  itself, 
that  can  be  relied  upon  in  cases  of  sympathetic  affec- 
tion of  the  eye.  It  must  be  extremely  doubtful 
whether  intra-ocular  neurotomy,  i.e.,  the  partial  slitting 
open  of  the  eye  as  above  described,  ever  permanently 
relieves  the  eye  so  treated,  or  offers  absolute  security 
against  sympathetic  irritation  in  the  other,  even  if  it 
is  performed  several  times  in  succession  or  in  one  dis- 
trict after  another.  Spencer  Watson  (1874:)  cites  a 
case  which  was  operated  upon  by  Ed.  Meyer's  method, 
in  which  the  primary  result  was  very  satisfactory,  but 
it  was  not  permanent,  and  enucleation  had  to  be  per- 
formed at  a  later  date.  On  the  other  hand,  there  is 
no  operation  by  which  we  can  be  sure  of  dividing  all 
the  ciliary  nerves  without  doing  any  injury  to  the 
optic  nerve.  As  for  myself,  I  can  see  no  indications 
for  such  an  operation ;  for,  in  the  case  suggested  by 
v.  Wecker,  we  must  not  only  postpone  enucleation,  but 
every  operation  on  the  injured  eye,  for  it  may  still  be 
saved  ;  whilst  if  this  eye  is  blind,  we  must  at  the  same 
time  divide  both  ciliary  and  optic  nerves  for  the  pur- 
pose of  terminating  the  irritation  which  they  inces- 
santly keep  up. 

Among  the  opinions  of  various  operators,  on  the 
division  of  the  ciliary  and  optic  nerves,  we  may  quote 
that  of  Mooren  (1869) :  "  I  can  hardly  believe,  in  any 


182  SYMPATHETIC   DISEASES    OF   THE   EYE. 

case,  that  division  of  the  ciliary  nerves  in  the  orbit  can 
attain  the  purpose  which  its  supporters  claim  for  it ; 
for,  after  fifty  or  sixty  experimental  operations  for  the 
division  of  various  branches  of  the  trigemirms,  although 
I  have  usually  seen  a  momentary  and  brilliant  result, 
yet  it  has  rarely  been  permanent.  The  desired  effect 
disappeared  as  soon  as  the  ends  of  the  nerves  reunited." 
Y.  Arlt  also  cites  a  case  in  the  Zeitschrift  der  Wiener 
Aerzte,  "  in  which  he  was  sure  that  the  ciliary  nerves 
became  reunited  after  once  being  divided."  We  have 
a  perfect  right  to  look  at  the  subject  from  this  point 
of  view,  for  up  to  this  time  we  have  had  no  satisfac- 
tory assurance  of  the  length  of  time  during  which  the 
favorable  result  continues  in  cases  of  division  of  the 
nerves  outside  the  eye.  We  can  only  assume  that  the 
ciliary  nerves  have  been  successfully  divided  when  the 
cornea  and  ciliary  body  become  totally  insensible  to  the 
touch  (or  pressure)  after  the  operation.  Restoration 
of  sensibility  in  either  of  these  regions  shows  that  the 
branches  of  these  nerves  had  subsequently  reunited. 
I  will  at  this  place  report  a  case  recently  under  my 
own  observation,  in  which  reunion  did  take  place,  and 
at  a  relatively  early  period. 

A  young  man  had  been  wounded  in  the  left  eye  a 
short  time  before  by  a  flying  chip  of  wood.  This  eye 
now  shows  diminished  tension  ;  the  ciliary  body  is 
sensitive  to  pressure.  There  is  slight  ciliary  injec- 
tion, the  cornea  is  perfectly  normal,  the  iris  is  dull  in 


THERAPEUTICS.  183 

color,  its  periphery  is  bulged  forward  in  knob-like 
processes,  and  the  margin  of  the  pupil  is  attached  to  a 
thick  membrane  which  covers  the  pupil.  Perception 
of  light  is  entirely  destroyed.  The  patient  now  comes 
for  advice,  complaining  that  for  some  time  his  right 
eye  has  been  momentarily  sensitive  to  light,  and  that 
he  cannot  use  it  for  any  close  work.  The  objective 
examination  of  this  eye  shows  that  it  is  normal  in 
every  respect.  As  the  left  eye  is  liable  at  any  time  to 
excite  sympathetic  irritation,  while  the  complaints 
which  the  patient  now  makes  may  be  regarded  as  the 
commencement  of  this  condition,  optico-ciliary  neu- 
rotomy  (as  Scholer  proposes  to  call  the  operation  which 
we  are  now  discussing)  is  performed — October  30, 
1880 — instead  of  enucleation. 

I  open  the  conjunctiva  over  the  tendon  of  the  rectus 
externus,  and  extend  the  incision  in  an  upward,  and 
afterward  in  a  downward  curve,  toward  the  insertions 
of  the  superior  and  inferior  recti.  1  next  take  up  the 
tendon  of  the  rectus  externns  on  the  strabismus-hook, 
and  carry  the  two  ends  of  a  catgnt  thread,  No.  0 
(armed  with  a  needle  at  each  end),  through  muscle  and 
conjunctiva.  I  then  divide  the  tendon,  and  hand  the 
threads  with  the  muscle  and  conjunctiva  to  the  assist- 
ant, to  draw  down  into  the  external  angle  of  the  eye- 
lids. The  next  step  consists  in  rotating  the  eyeball 
toward  the  nose,  after  which  I  penetrate,  with  scissors 
curved  on  the  flat,  into  the  cavity  of  the  orbit,  divide 


184  SYMPATHETIC   DISEASES    OF   THE   EYE. 

the  optic  nerve,  and  then  alternately  opening  and 
closing  the  scissors,  I  denude  the  whole  posterior  sur- 
face of  the  globe  as  thoroughly  as  possible.  The  scis- 
sors are  now  laid  aside.  I  then  take  a  curved  teno- 
toine,  push  it  into  the  orbit,  and  denude  the  posterior 
portion  of  the  globe  still  more  thoroughly,  turning  the 
eye  again  and  again  as  far  as  possible  toward  the  nose. 
The  subsequent  hemorrhage  is  comparatively  slight. 
The  rectus  extern  us  is  now  replaced  and  advanced  by 
sutures ;  the  two  needles  are  passed  through  the  con- 
junctiva (which  was  previously  left  standing  near  the 
margin  of  the  cornea),  then  removed,  and  the  ends  of 
the  sutures  tied.  Finally,  a  pressure-bandage  is  ap- 
plied. 

November  2,  1878,  three  days  after  the  operation, 
the  cornea  has  lost  all  its  sensitiveness,  and  the  ciliary 
body  is  insensible  to  pressure.  The  ciliary  region  is 
now  considerably  injected,  and  the  patient  complains 
of  violent  pain.  The  conjunctiva  also  is  extremely  con- 
gested and  very  sensitive  to  the  touch.  The  sensibility 
of  the  entire  cornea  soon  returns.  The  ciliary  body  con- 
tinues insensible  for  a  considerable  length  of  time.  On 
the  last  examination,  however — December  10,  1878 — 
the  upper  and  outer  portions  of  the  ciliary  body  are 
distinctly  painful  to  pressure.  The  eyeball  is  rather 
pale,  deviates  slightly  outward,  and  is  decidedly  soft 
to  the  touch.  The  vague  complaints  about  the  unin- 
jured eye  continue.  Finally,  enucleation  is  performed 


THERAPEUTICS.  185 

by  Prof.  v.  Jaeger.  And  what  did  we  then  discover? 
The  stump  of  the  optic  nerve  attached  to  the  globe 
consisted  of  two  parts.  The  optic  nerve  had  been 
wholly  severed  by  the  neurotomy,  but  the  two  ends  had 
reunited;  not  indeed  in  perfect  apposition,  the  two 
surfaces  of  the  original  incision  being  still  in  part 
plainly  visible. 

The  history  of  this  case  has  also  taught  us  the  method 
by  which  the  operation  is  performed.  Schweigger 
divides  the  internal  rectus  in  the  middle  of  its  inser- 
tion, instead  of  the  external  rectus,  and  reunites  it  af- 
ter the  operation  with  sutures,  as  previously  described. 
After  dividing  the  optic  nerve,  he  rotates  the  posterior 
pole  of  the  eye  forward,  by  means  of  a  small,  sharp 
hook  inserted  into  the  sclerotica  near  the  optic  nerve,  so 
that  the  insertion  of  the  nerve  is  brought  forward  into 
view.  In  this  way  we  can  carefully  denude  the  whole 
sclerotica,  so  that  the  ciliary  nerves  shall  be  divided 
without  the  shadow  of  a  doubt.  But  are  we  sure  that 
some  branches  do  not  reunite?  If  this  should  happen, 
it  is  not  necessary  for  our  purpose  to  take  it  for  granted 
that  the  divided  ends  of  the  same  nerve  should  always 
reunite  with  each  other.  The  case  which  we  have  just 
cited  does  not  testify  absolutely  in  favor  of  the  com- 
plete reliability  of  optico-ciliary  neurotomy.  There- 
fore the  operation  must  be  tested  further,  perhaps 
improved  a  great  deal,  before  we  can  employ  it  with 
confidence  as  a  perfect  substitute  for  enucleation, 


186  SYMPATHETIC   DISEASES    OF   THE   EYE. 

Meanwhile,  we  hope  that  no  operator  who  puts  full 
trust  in  it,  and  employs  it  as  a  preventive,  in  the  be- 
lief that  he  thus  insures  the  other  eye  from  danger  as 
thoroughly  as  he  would  do  by  enucleation,  may  ever 
be  terribly  undeceived  by  seeing  a  patient,  in  whom 
he  has  thus  performed  optico-ciliary  neurotomy,  reap- 
pear for  advice  at  a  later  date,  with  all  the  symptoms 
of  a  genuine  irido-cyclitis  ! 

Among  other  operations  proposed  as  substitutes  for 
enucleation,  we  may  next  mention  the  production  of 
purulent  choroiditis  by  the  early  introduction  of  a 
thread  into  the  threatening  eye.  It  is  said  that,  by 
passing  a  thread  through  all  the  tunics  of  the  eye, 
and  letting  it  remain  until  a  slight  serous  swelling 
(chemosis)  of  the  conjunctiva  indicates  that  purulent 
choroiditis  (panophthalmitis)  has  begun,  the  eye  gradu- 
ally shrivels  and  becomes  insensible.  Moreover,  it  is 
said  that  the  danger  of  sympathetic  irritation  is  thus 
entirely  removed,  owing  to  the  fact  that  the  purulent 
inflammation  has  more  or  less  completely  destroyed 
the  ciliary  nerves.  Y.  Graefe  refers,  at  three  differ- 
ent periods  (I860,  1863,  and  1866),  to  this  manner 
of  producing  artificial  atrophy,  which  had,  however, 
long  before  been  resorted  to  for  an  entirely  different 
purpose,  in  the  case  of  hypertrophied  eyeballs.  Feuer 
also  has  lately  revived  the  same  proposition.  Just 
here,  however,  we  have  nothing  to  do  with  the  influ- 
ence of  this  procedure  in  diminishing  the  size  of  en- 


THERAPEUTICS.  187 

larged  eyeballs,  but  only  with  its  relations  to  enucle- 
ation.  In  spite  of  v.  Graefe's  recommendations,  based, 
moreover,  as  far  as  we  can  see,  on  entirely  theoretical 
grounds,  we  must  emphasize  the  fact,  which  is  easily 
evident  from  his  own  last  words  on  this  point,  that  he 
had  never  made  any  practical  use  of  this  method  in 
cases  of  sympathetic  ophthalmia.  These  are  his  re- 
marks in  1866  :  "  It  might,  perhaps •,  be  rational  under 
certain  cir 'cumstanf.es ;  especially  after  wounds  or  op- 
erations, when  nothing  more  can  be  hoped  for  in  the 
eye  in  question,  to  increase  the  diffuse  purulent  inflam- 
mation already  present,  by  inserting  a  thread  for  two 
or  three  days.  The  patient  suffers  far  less  from  the 
panophthalmitis  (if  soothed  with  cataplasms)  than  he 
would  suffer  from  a  subacute  cyclitis,  gains  a  less 
sensitive  stump,  which  bears  an  artificial  eye  excel- 
lently, and  finally  is  saved  from  the  danger  of  trans- 
mission of  irritation  to  the  other  eye." 

But  if  this  method  really  offers  so  great  advan- 
tages, why  had  v.  Graefe,  up  to  that  time,  never  re- 
sorted to  it  ?  It  seems  to  me  that  he  had  some  fear 
that  it  might  act  as  a  double-edged  sword.  For,  say- 
ing nothing  of  the  fact  that  even  panophthalmitis, 
and  the  "  less  sensitive  "  stump,  do  not  offer  complete 
security  against  sympathy,  the  thread,  although  it 
might  not  increase  the  inflammation  to  genuine  pan- 
ophthalmitis, might  cause  cyclitis  of  a  much  more 
severe  and  dangerous  type.  Under  such  circumstances, 


188  SYMPATHETIC   DISEASES   OF   THE   EYE. 

this  method  might  not  only  not  remove  the  danger  of 
sympathetic  ophthalmia,  but  even  favor  the  outbreak 
of  this  affection  in  the  same  way  as,  when  a  foreign 
body  lies  hidden  in  the  eye,  we  cannot  hope  for  a  con- 
dition of  permanent  rest. 

Is  there  any  need  of  my  giving  anything  more  than 
a  hint  of  the  method  proposed  by  Barton,  which  con- 
sisted in  abscising  the  cornea,  removing  the  lens,  and 
subsequently  applying  poultices  to  the  remnant  of  an 
eye  in  which  a  foreign  body  still  lies  encapsuled  ?  Or 
shall  I  mention  the  proposition  of  Verneuil  (1874:),  who, 
after  unfavorable  experience  in  four  cases  of  enuclea- 
tion,  advises  us  to  close  the  eyelids  by  uniting  their 
edges  (blepharoraphy),  and  illustrates  the  useful  re- 
sult of  this  method  by  two  pertinent  cases  ? 

Barton  tells  us  that,  after  abscising  the  whole  ante- 
rior portion  of  the  eyeball,  and  applying  poultices  for 
a  few  days,  the  foreign  body,  which  has  previously 
been  lodged  in  the  vitreous,  is  generally  found  lying 
somewhere  in  the  conjunctival  sac.  This  operation 
will,  however,  hardly  take  the  place  of  enucleation, 
from  the  fact  that  it  may  possibly  be  followed  by 
excessive  secondary  hemorrhage,  as  well  as  by  violent 
and  tedious  panophthalmitis,  so  that  the  eyeball  is 
gradually  reduced  to  a  minute  stump.  In  Verneuil's 
cases,  the  irritation  of  the  eye  which  led  to  sympathy 
on  the  part  of  the  other,  depended,  as  Laqueur  has 
already  remarked,  on  a  lack  of  suitable  protection. 


THERAPEUTICS.  189 

Under  similar  exceptional  circumstances,  therefore,  this 
operation  may  also  be  employed. 

Iridectomy  is  the  last  operation  to  be  mentioned. 
Are  we  to  perform  it  on  the  eye  which  causes  sym- 
pathy ?  Under  one  circumstance  only :  when  the  iris 
(the  eye  being  otherwise  unharmed)  has  become  incar- 
cerated in  the  peripheral  wound  in  the  cornea,  after 
an  injury  or  operation,  as  well  as  after  spontaneous 
perforation  of  the  cornea.  In  such  cases  we  may  have 
neuralgia  of  the  eye  first  affected,  or  sympathetic  in- 
flammation of  the  second  eye.  Iridectomy  is  then  of 
great  benefit,  for  by  this  operation  we  can  abscise  the 
imprisoned  bit  of  iris,  as  well  as  the  crushed  ciliary 
nerves,  and  succeed  in  saving  both  eyes  from  danger. 
But  when  the  incarceration  of  the  iris  has  already 
induced  irido-cyclitis,  or  when  the  latter  affection  has 
originated  from  any  cause  whatever,  iridectomy  is  of 
no  avail,  and  cannot  in  any  respect  be  advantageously 
resorted  to  as  a  substitute  for  enucleation. 

When  the  sympathetic  symptoms  can  be  attributed 
to  the  crushing  of  the  nerve  during  enucleation,  or  to 
secondary  imprisonment  of  the  stump  of  the  nerve  in 
the  cicatrix,  we  may  endeavor  to  remove  the  irritating 
cause  by  subsequent  excision  of  the  cicatrix.  But 
even  then  we  shall  only  gain  permanent  results  under 
the  same  circumstances  under  which  enucleation  would 
originally  have  been  beneficial.  Thus,  Hasket  Derby 
reports  a  case  of  fully-developed  irido-cyclitis  which 


190  SYMPATHETIC   DISEASES    OF   THE   EYE. 

could  not  be  cured  by  resection  of  the  stump  of  the 
nerve  (page  154) ;  while,  on  the  other  hand,  Mooren 
succeeded  in  permanently  relieving  the  ciliary  hyper- 
sesthesia  in  his  case  (page  153)  by  some  peculiar 
method  (which  may  really  have  consisted  in  exsecting 
the  stump  of  the  nerve).  In  my  own  case  (page  136)  I 
proposed  an  operation  to  the  patient,  intending  to  dis- 
sect the  optic  nerve  away  from  all  its  surrounding  tis- 
sues as  far  back  as  the  optic  foramen,  and  then  to 
abscise  it.  If  the  irritating  cause  were  situated  in  the 
orbital  portion  of  the  nerve,  we  might,  perhaps,  suc- 
ceed in  relieving  the  tormenting  pain  from  which  the 
patient  has  suffered.  Up  to  this  time,  however,  my 
patient,  to  whom,  of  course,  I  could  not  guarantee  per- 
fect success,  has  not  been  able  to  make  up  his  mind  to 
consent  to  the  operation. 

We  have  now  finished  our  discussion  of  the  opera- 
tions which  may  be  practised  upon  the  eye  originally 
affected,  but  we  have  not  yet  exhausted  our  account 
of  the  operative  therapeutics  of  sympathetic  ophthal- 
mia. We  still  have  to  inquire  what  operations,  if  any, 
are  permissible  on  the  eye  which  has  become  affected  by 
sympathy.  In  these  cases  also  it  is  important  for  us 
to  separate  the  various  forms  and  stages  of  sympathy. 
We  cannot  operate  on  the  second  eye  so  long  as  it  is 
intact,  or  merely  exhibits  simple  irritation,  or  slight 
functional  disturbances. 

Iritis  serosa  is  the  first  affection  of  the  uveal  tract 


THERAPEUTICS.  191 

that  we  are  to  consider.  In  general,  this  type  of 
iritis  will  not  need  any  heroic  treatment,  and  we 
ought  to  act  toward  it  with  much  greater  reservation 
than  in  a  case  of  the  same  disease  which  does  not  de- 
pend upon  sympathetic  irritation.  For  the  sympa- 
thetic form  is  evidently  dependent  upon  some  irritation 
of  the  nerves,  an  irritation  whose  increase  we  dread  so 
exceedingly  that  we  always  energetically  oppose  enu- 
cleation  of  the  irritating  eye,  so  long,  at  least,  as  the 
iritis  serosa  persists.  When  the  common  form  of 
serous  iritis  continues  for  a  long  time,  and  will  not 
yield  to  the  usual  remedies,  we  cannot  do  anything 
better  than  to  perform  iridectomy.  But,  just  as  we 
should  not  operate  on  an  eye  affected  by  sympathy  so 
long  as  there  seems  to  be  no  real  danger  from  delay, 
so  we  should  not  be  too  hasty  in  performing  an  iridec- 
tomy in  cases  of  sympathetic  serous  iritis.  As  v. 
Graefe  said,  in  1866  :  "  I  remember  only  two  cases  in 
which  I  felt  obliged  to  perform  paracentesis  of  the 
cornea,  and  once  to  perform  iridectomy  upward,  in 
cases  of  obstinate  iritis  serosa.  In  all  of  these,  how- 
ever, the  desired  purpose  was  effected." 

Simple  plastic  iritis  with  but  few  posterior  adhe- 
sions of  the  pupillary  margin,  the  intermediate  por- 
tions of  the  iris  reacting  well  to  atropia,  is  to  be 
placed  on  the  same  level  with  serous  iritis,  so  far  as 
the  abstinence  from  operative  treatment  in  sympa- 
thetic irritation  is  concerned. 


192  SYMPATHETIC   DISEASES    OF    THE   EVE. 

"We  have,  however,  an  exceptional  state  of  affairs 
in  cases  of  total  exclusion  of  the  pupil  Ijy  circular  pos- 
terior adhesions.  Let  us  at  this  point  recall  our  pre- 
vious remarks  on  this  subject  (pages  76  and  80).  The 
differential  diagnosis  between  the  condition  in  which 
the  iris  is  bulged  forward  by  the  fluid  of  the  posterior 
chamber  on  the  one  hand,  or  by  the  masses  of  exuda- 
tion dependent  on  plastic  irido-c}Tclitis  on  the  other, 
lies  chiefly,  in  our  judgment,  in  the  degree  of  hardness 
or  softness  of  the  eyeball,  in  comparison  with  the  nor- 
mal condition.  If  the  fluids  of  the  posterior  chamber 
have  bulged  the  iris  forward,  the  eye  will  be  doubt- 
fully, or  perhaps  distinctly  harder  to  the  touch  ;  if  exu- 
dations have  been  at  work,  the  eye  will  be  decidedly 
soft.  When  the  periphery  of  the  iris  is  bulged  for- 
ward in  knob-like  masses,  the  eyeball,  however,  being 
soft  to  the  touch,  the  case  is  quite  different  from  that 
in  which,  with  similar  appearances  on  the  part  of  the 
iris,  we  can  prove  that  the  eye  is  harder  than  normal. 
This  latter  condition  only  is  the  one  with  which  we  are 
now  concerned. 

The  literature  at  our  command  does  not  give  a  su- 
perfluity of  advice  for  cases  in  which  sympathetic  sec- 
ondary glaucoma  is  apprehended,  or  in  the  presence  of 
symptoms  which  denote  its  approach.  V.  "Wecker 
(1879)  thinks  that,  "on  account  of  the  violent  pain 
from  which  the  patients  often  suffer  in  case  of  an  at- 
tack of  glaucoma  after  the  development  of  complete 


THERAPEUTICS.  193 

posterior  adhesions,"  we  should  confine  ourselves  ex- 
clusively to  paracentesis  of  the  cornea  or  sclerotomy  ; 
we  should  never  think  of  touching  the  iris,  or  of  per- 
forming iridectoniy.  "  We  shall  hot,  as  a  rule,  suc- 
ceed," says  he,  "  in  loosening  those  fragments  of  the 
iris  which  adhere  to  the  anterior  capsule  of  the  lens, 
and  if  we  are  so  fortunate  as  to  succeed  in  a  few  cases, 
the  eye  will  be  so  much  irritated  by  the  contusion,  that 
the  momentary  benefit  which  we  seem  to  have  won  will 
be  lost  again  by  closure  of  the  new  pupil,  and  deterio- 
ration of  the  function  of  vision." 

Unfortunately,  I  cannot  assent  to  this  view;  for  in 
cases  of  simple  iritis,  iridectomy  is  unnecessary,  while 
in  those  in  which  the  posterior  surface  of  the  iris  has 
become  adherent  to  the  anterior  capsule,  the  oper- 
ation is  hardly  practicable.  But  in  that  condition 
of  affairs  which  we  are  now  discussing,  there  is  no 
doubt  that  we  can  excise  a  piece  of  the  iris  with  the 
effect  of  restoring  the  communication  between  the  an- 
terior and  posterior  chambers.  By  this  means  we  may 
also  successfully  oppose  the  inflammatory  attacks  of 
secondary  glaucoma,  as  well  as  of  glaucoma  itself,  by 
removing  the  inducing  cause.  The  following  instruc- 
tive clinical  history  niay  serve  to  throw  light  upon 
what  we  have  just  said. 

A  man  about  thirty-one  years  of  age  was  seen  at  the 
Clinic  April  30,  1876.  On  January  24, 1876,  a  cramp- 
iron  had  been  projected  against  his  left  eye.  The 


194  SYMPATHETIC   DISEASES    OF   THE    EYE. 

patient  suffered  but  little  pain  after  the  injury;  the 
sight  of  the  wounded  eye  was  diminished,  but  he  could 
still  see  pretty  well.  The  eye  was  very  sensitive  to  light, 
and  a  few  days  thereafter  it  began  to  redden.  The 
"inflammation"  passed  off  in  a  fortnight,  but  vision 
had  at  that  time  diminished  still  further.  The  patient 
kept  at  his  work  for  another  fortnight,  but  as  it  made 
the  eye  congested  and  painful,  he  applied  a  bandage 
over  it  and  stopped  work.  Still  a  fortnight  later,  six 
weeks  in  all,  after  the  injury,  the  right  eye  became 
affected,  and  was  injected  and  painful.  The  inflam- 
mation continued  with  occasional  exacerbations,  so 
that  vision  was  gradually  reduced  to  its  present  amount. 
The  examination  shows  the  following  state  of  things 
in  the  left  eye :  A  cicatrix,  three  or  four  millimetres  in 
length,  in  which  the  iris  has  become  incarcerated,  lies 
in  the  sclerotica,  at  the  outer  edge  of  the  cornea,  just 
above  its  horizontal  diameter.  The  iris,  which  is  al- 
tered in  color,  and  has  partially  lost  its  striated  ap- 
pearance, is  tied  down  to  the  anterior  capsule  of  the 
lens  by  numerous  adhesions,  whilst  the  pupil  has  been 
elongated  toward  the  cicatrix  in  such  a  manner  that  it 
seems  as  if  a  regular  iridectomy  had  been  performed. 
The  ophthalmoscope  reveals  the  bright  edge  of  the 
crystalline  lens  at  the  place  where  the  iris  is  deficient. 
We  know,  therefore,  that  the  lens  was  not  dislocated 
by  the  injury.  The  vitreous  is  so  full  of  floating 
opacities  that  we  cannot  get  an  image  of  the  back- 


THERAPEUTICS.  195 

ground  of  the  eye.  The  whole  ciliary  region  is  slightly 
congested.  The  tension  of  the  eye  is  not  noticeably 
changed ;  i.e.,  the  eye  is  neither  too  soft  nor  too  hard. 
Tactile  exploration  shows  that  the  outer  and  upper 
portion  of  the  ciliary  region  (not  precisely  in  corre- 
spondence with  the  place  where  the  iris  is  incarcerated) 
is  sensitive  to  pressure.  The  sight  of  this  eye  has 
decreased  to  one-fourth,  or,  with  a  very  weak  concave 
glass,  to  one-third  of  the  normal  amount. 

The  right  eye  shows  slight  injection  of  the  ciliary 
region.  The  pupil  is  completely  excluded  by  poste- 
rior adhesions,  and  the  periphery  of  the  iris  bulged 
forward,  especially  in  the  upper  half  of  the  iris,  which 
is  altered  in  color  and  appearance.  The  pupil  is  filled 
with  a  membrane  which  is  thin  and  transparent  at  the 
centre,  but  thick  at  the  circumference.  The  tension 
of  the  eye  is  perceptibly  increased,  but  not  to  a  high 
degree.  A  sensitive  spot,  corresponding  precisely  in 
location  to  the  one  discovered  in  the  left  eye,  is  found 
oy  careful  palpation.  Vision  is  reduced  to  one-seventh 
of  the  normal  amount. 

What  are  we  to  do  ?  We  cannot  enucleate  the  in- 
jured eye,  even  did  it  possess  only  the  slightest  possible 
trace  of  vision.  It  is  as  clear  as  possible  that  we  can- 
not enucleate  one  eye  with  one-third  of  normal  vision 
in  order  to  save  the  other,  which  at  present  has  only 
one-seventh  of  normal  vision,  not  even  if  we  had  any 
faith  whatever  in  the  efficacy  of  enucleation  under 


196  SYMPATHETIC   DISEASES   OF    THE   EYE. 

such  circumstances.  On  the  other  hand,  I  am  re- 
strained from  operating  on  the  eye  sympathetically 
affected,  by  the  dread  which  such  an  operation  should 
always  inspire. 

The  patient  is  sent  to  bed,  receives  a  solution  of 
atropia  for  his  left  eye  (without,  however,  dilating  the 
pupil),  and  a  course  of  inunction  is  begun.  A  week 
later  (May  6th),  after  three  inunctions  (not  to  these, 
but  to  the  suitable  regimen  do  I  ascribe  the  benefit) 
the  ciliary  injection  has  disappeared  from  both  eyes. 
The  ciliary  body  in  each  eye  is  no  longer  sensitive  to 
the  touch.  On  the  next  morning,  however,  pain  is  felt 
in  the  right  eye,  increases  all  day  long,  and  at  night 
becomes  very  violent.  May  8th. — The  tension  of  the 
right  eye  (the  one  affected  by  sympathy)  is  noticeably 
increased,  the  lids  are  slightly  swollen,  ciliary  injection 
is  excessive,  the  cornea  is  slightly  hazy,  and  the  iris  is 
bulged  forward  much  more  than  at  any  previous  time. 
Pain  is  also  felt  at  the  sensitive  spot  in  the  ciliary  region 
(while  the  corresponding  spot  in  the  wounded  eye  is  free 
from  pain),  and  vision  is  reduced  to  counting  fingers 
at  one  metre.  In  brief,  the  right  eye  exhibits  all  the 
symptoms  of  acute  glaucoma.  May  12th. — As  vision 
has  not  increased,  an  iridectomy  is  made  inward,  a 
large  piece  of  iris  being  excised.  The  incision  heals, 
and  the  anterior  chamber  is  restored.  The  iris  no 
longer  bulges  forward  at  its  periphery,  but  lies  in  a, 
plane.  The  blood  in  the  anterior  chamber  is  soon 


THERAPEUTICS.  197 

absorbed,  pain  and  sensitiveness  of  the  ciliary  body 
disappear,  and  tension  becomes  normal  ;  but  the  ciliary 
injection  is  still  present  (May  18th). 

June  9th. — Both  eyes  are  perfectly  free  from  irri- 
tation, and  their  tension  is  normal.  Right  eye :  The 
cornea  is  slightly  cloudy  near  the  cicatrix  left  after 
the  incision,  but  is  otherwise  transparent.  The  newly 
formed  pupil  is  partially  covered  with  a  membrane, 
which,  however,  permits  light  to  enter  the  eye  at  its 
periphery.  The  iris  lies  in  its  normal  position.  Left 
eye:  The  floating  opacities  in  the  vitreous  have  de- 
creased so  much  that  the  retinal  vessels  and  optic  papilla 
can  be  dimly  seen  by  means  of  the  ophthalmoscope. 

The  result  of  the  case  may  be  thus  formulated  in 
brief :  The  injured  left  eye  has  one-half  of  normal 
vision;  the  sympathetically  affected  right  eye,  one- 
tenth  of  normal  vision. 

"  I  always  operate  when  the  periphery  of  the  iris 
bulges  forward,"  as  I  said  before  in  speaking  of  sec- 
ondary glaucoma  produced  by  sympathetic  iritis.  This 
operation  consists,  as  is  evident  from  the  foregoing 
clinical  case,  in  iridectomy,  which  has  an  undeniably 
beneficial  effect.  Sclerotomy,  i.e.,  the  formation  of  a 
large  wound  in  the  sclerotica  at  the  edge  of  the  cornea, 
cannot  be  performed  under  the  above  circumstances 
(bulging  of  the  iris),  owing  to  the  excessive  protrusion 
of  the  periphery  of  the  iris  ;  while,  on  the  other  hand,  if 
it  could  be  performed,  it  would  not  fulfil  the  indication 


198  SYMPATHETIC   DISEASES    OF   THE    EYE. 

of  restoring  the  communication  between  the  anterior 
and  posterior  chambers. 

Secondary  glaucoma  after  sympathetic  iritis  seems 
to  me  to  be  the  only  condition  that  allows  of  operative 
interference.  For,  as  serous  iritis,  as  well  as  plastic 
iritis,  does  not  demand  such  treatment,  in  the  same 
way  we  cannot  operate  during  the  height  of  irido- 
cyclitis,  because  by  so  doing  we  increase  the  morbid 
process  which  in  turn  rapidly  leads  to  atrophy  of  the 
eye.  The  unfavorable  results  which  I  had  obtained 
from  iridectomy,  when  performed  under  such  circum- 
stances, led  me  over  to  the  side  of  the  large  majority 
of  oculists  of  the  present  day,  who  will  not  resort  to 
any  operation,  not  even  to  an  iridectomy,  in  cases  of 
plastic  irido-cyclitis.  When  v.  Graefe  performed  iri- 
dectomy "  even  in  a  simple  condition  of  affairs,"  but 
like  all  other  operators  gained  no  beneficial  results,  he 
asked  himself  whether  "  the  iridectomy  might  not  have 
been  performed  at  too  late  a  date."  Or  whether  "  a 
broad  excision  of  the  iris  toward  the  extreme  peri- 
phery might  not  be  of  greater  benefit,  especially  if 
we  reflect,  that  when  the  iris  has  once  begun  to  ad- 
here to  the  anterior  capsule  of  the  lens,  the  adhesion 
advances  rapidly  toward  the  ciliary  processes."  In 
other  words,  v.  Graefe  inquired  whether,  if  he  made 
the  incision  in  the  sclerotica  as  in  the  cataract  oper- 
ation which  goes  by  his  name,  the  iris  would  not  pre- 
sent itself  more  broadly,  and  in  a  more  suitable  po- 


THERAPEUTICS.  199 

sition  for  being  grasped  by  the  forceps,  so  that  a  much 
larger  piece  might  be  excised. 

V.  Graefe's  recommendation  of  such  a  method  is 
based  on  the  favorable  result  which  he  obtained  in  one 
case  of  this  sort — the  only  one  which  he  had  oppor- 
tunity of  reporting  up  to  that  date.  But  many  ocu-. 
lists  have  since  discovered  that  v.  Graefe's  hopes  were 
too  sanguine.  Mooren,  for  example  (1869),  expresses 
doubt  whether  even  the  earliest  and  most  successful 
iridectomy  can  be  of  any  avail  at  all  in  the  malignant 
type  of  plastic  irido-cyclitis,  for  in  two  cases  in  which 
he  performed  the  operation  at  the  very  outbreak  of 
the  disease,  and  under  relatively  favorable  circumstan- 
ces, the  result  was  fatal  to  vision. 

Although  a  few  cases  of  the  favorable  effects  of  one 
or  repeated  iridectomies  in  iritis  maligna  have  since 
been  reported  (Hugo  Muller,  Grossmann,  Pfliiger),  we 
must  hold  firm  to  the  axiom,  that  only  after  the  pro- 
cess has  become  entirely  extinct  (by  no  means  sooner 
than  a  year  after  the  outbreak  of  the  sympathetic  in- 
flammation) can  we  decide  whether  an  operation  is  to 
be  undertaken  or  not.  The  condition  of  the  eye  after 
such  a  lapse  of  time  is  frequently  a  great  deal  more 
favorable  than  we  should  have  deemed  possible  at  the 
outbreak  of  the  affection,  and  many  an  eye  that  a  few 
weeks  after  the  appearance  of  iritis  maligna  seemed  to 
have  fallen  a  prey  to  total  atrophy,  offers  itself,  at  the 
end  of  a  year,  free  from  irritation,  with  proportionally 


200  SYMPATHETIC    DISEASES   OF    THE   EYE. 

fair  tension,  and  prompt  quantitative  reaction  to  light, 
even  when  the  pupil  is  blocked  up;  or,  when  the  pu- 
pil is  clear,  or  but  slightly  veiled,  exhibits  a  surpris- 
ing degree  of  vision.  In  the  latter  case,  we  should 
be  well  on  our  guard  against  operating  with  the  inten- 
tion of  improving  sight.  In  the  former,  on  the  con- 
trary, we  should  not  delay  in  our  attempt  to  make  a 
path  for  the  rays  of  light  to  reach  the  retina.  In  such 
cases,  however,  we  cannot  expect  any  benefit  from 
simple  irideetomy,  for  the  whole  surface  of  the  iris 
being  adherent  to  the  capsule  of  the  lens,  it  is  impos- 
sible to  draw  or  tear  away  the  iris  with  its  adherent 
membranes.  We  can  then  only  attain  our  object  by  si- 
multaneously opening  and  removing  the  anterior  cap- 
sule, giving  rise  at  the  same  time  to  traumatic  cata- 
ract. In  other  words,  we  must  resort  to  "  extraction 
of  the  lens,  with  simultaneous  iridectomy  and  lacer- 
ation of  the  false  membranes."  (V.  Graefe.) 

A  narrow  knife — e.g.,  v.  Graefe's  cataract-knife — is 
entered  at  the  upper  and  outer  edge  of  the  cornea, 
nearly  on  a  level  with  the  tangent  of  the  highest  point 
of  its  upper  margin.  It  is  next  to  be  pushed  through 
the  iris,  afterward  behind  the  iris,  and  finally  through 
the  lens  to  a  corresponding  point  of  counter-puncture, 
so  that  the  sclerotic  coat  is  opened  at  the  upper  edge 
of  the  cornea  by  a  linear  incision  ten  millimetres  in 
length.  We  then  introduce  the  forceps  in  such  a 
manner  that  one  branch  passes  in  front  of  the  iris,  the 


THERAPEUTICS.  201 

other  behind  it  (really  into  the  lena  behind  the  ante- 
rior capsule,  which  is  adherent  to  the  iris),  and  try  to 
draw  the  whole  membranous  mass  between  the  lips  of 
the  incision,  in  order  to  excise  it.  In  case  the  mem- 
branes will  not  follow  the  traction  (we  should  not 
pull  too  forcibly),  we  must  cut  through  the  mem- 
branes, with  a  pair  of  fine  scissors,  in  such  a  manner 
that  a  free  triangular  bit  of  membrane  lies  between 
the  branches  of  the  forceps,  by  means  of  which  the 
bit  can  be  removed  from  the  eye.  Then  follows  the 
evacuation  of  the  lens,  which,  during  this  manipula- 
tion has  already  been  broken  up  into  small  pieces.  If 
the  opening  in  the  membranous  iris  closes  again  after 
the  operation,  or  if  irido-cyclitis  attacks  the  eye  which 
has  lost  its  lens,  we  should  (after  opening  the  an- 
terior chamber  with  v.  Graefe's  knife)  simply  divide 
the  diaphragm  by  v.  Wecker's  forceps-scissors,  one 
branch  being  passed  through  the  iris  and  behind  it, 
and  the  other  lying  in  front  between  the  cornea  and 
the  iris  (iritomy).  In  the  case  described  on  pages  52 
to  55,  double  iritomy  enabled  the  eye  affected  by  sym- 
pathy to  see  fingers  at  six  feet  (with  proper  cataract- 
glasses),  while  the  other  eye  gained  vision  equal  to  one- 
eighth  of  the  normal  amount.* 

*  Pagenstecher  (1881)  is  of  the  opinion  that  such  an  operation 
as  is  here  described  is  a  mistaken  one,  and  that  we  can  win  much 
better  results  by  making  an  iridectomy,  and  then  removing  the 

lens,  together  with  its  capsule,  with  a  flat  spoon. — TKS. 
9* 


202  SYMPATHETIC   DISEASES   OF   THE   EYE. 

Little  as  we  can  expect  from  the  operative  treat- 
ment of  sympathetic  inflammation  when  this  disease 
has  once  become  well  defined,  and  extremely  probable 
as  it  is  that  more  benefit  can  be  obtained  by  refrain- 
ing from  operative  interference,  we  have  no  reason  to 
boast  of  the  results  of  medical  treatment.  Serous 
iritis  and  simple  plastic  iritis  (in  and  by  themselves 
by  no  means  greatly  to  be  dreaded,  as  we  have  .repeat- 
edly urged)  behave  toward  therapeutical  measures  like 
other  types  of  iritis  which  are  not  of  sympathetic 
origin.  But  therapeutics  have  no  power  over  a  genuine 
sympathetic  irido-cyclitis.  It  is,  indeed,  extremely 
doubtful  whether  even  the  most  energetic  measures, 
whether  mercurialization,  or  even  acute  mercurializa- 
tion,  in  a  case  of  the  latter  type,  can  save  an  eye, 
which,  on  the  other  hand,  may  recover  without  any 
employment  of  mercury  whatsoever. 

We  may  thus  sum  up  our  therapeutical  resources  in 
cases  of  injuries  of  the  eye  which  may  subsequently 
lead  to  sympathetic  inflammation.  If  an  eye  is  badly 
injured,  a  large  portion  of  its  contents  evacuated, 
vision  totally  lost,  and  a  foreign  body  undoubtedly 
present  in  its  interior,  it  is  best  to  enucleate  at  once, 
before  the  impending  panophthalmitis  makes  its  ap- 
pearance. If  the  wound  embraces  a  large  extent  of 
the  eye,  and  we  are  sure  that  no  foreign  body  remains 
behind  (or,  if  the  shape  of  the  eye  as  well  as  a  partial 
amount  of  vision  has  been  preserved,  even  if  it  is 


THERAPEUTICS.  203 

probable  that  a  foreign  body  is  still  lodged  within  the 
eye),  we  are  not  to  be  in  too  great  haste  to  enucleate. 
We  should  rather  put  the  patient  to  bed  in  a  darkened 
room,  and  drop  a  solution  of  atropia  into  the  eye  at 
regular  intervals.  If  we  think  it  can  still  be  of  any 
avail,  we  should  further  add  a  compress-bandage ;  and 
lessen  whatever  pain  is  felt,  by  hypodermic  injections 
of  morphia.  The  application  of  iced  compresses,  as 
well  as  of  leeches,  notwithstanding  their  frequent 
employment,  is  really  of  doubtful  benefit.  It  is  only 
in  the  exceptional  cases  in  which  the  patient  cannot 
bear  the  pressure-bandage  that  we  should  resort  to 
cold  applications.  We  should,  however,  remove  them 
the  moment  that  they  begin  to  feel  disagreeable  to 
the  patient,  and  simply  cover  the  eye  gently  with  a 
bit  of  cotton  cloth.  If  panophthalmitis  ensues,  we 
should  leave  the  pressure-bandage  on  as  long  as  the  pa- 
tient can  bear  it ;  afterward  warm  fomentations  (thin 
compresses  dipped  in  warm  tea,  or  poultices  of  farina- 
seed  or  wheat-bread  boiled)  are  indicated.  We  may 
also  try  Lelievre's  new  poultice-papers,  which  are 
strongly  recommended  by  Fronm  tiller. 

When  the  eye  becomes  purulent,  excessively  pain- 
ful, and  greatly  swollen,  we  may  attempt  relief  by 
opening  it.  But  when  the  panophthalmitis  begins  to 
show  signs  of  relapse,  we  should,  as  soon  as  possible, 
insist  upon  the  renewed  application  of  the  compress- 
bandages. 


204  SYMPATHETIC   DISEASES   OF   THE   EYE. 

If  several  weeks  have  passed  since  the  injury  (the 
patient  having  been  kept  perfectly  quiet  in  the  inter- 
val) and  the  panophthalmitis  has  diminished  propor- 
tionately, we  must  examine  the  eye  thoroughly  to  see 
whether  it  is  now  perfectly  quiescent  or  not.  If  it 
should  be  quiescent,  the  patient  may  have  our  consent 
to  resume  his  usual  occupation,  but  should  be  warned 
most  earnestly  to  take  notice  of  the  least  return  of  pain 
in  the  injured  eye,  and  to  report  for  advice  without  a 
moment's  loss  of  time.  If,  on  the  other  hand,  the  eye 
is  no  longer  spontaneously  painful,  but  still  continues 
sensitive  to  all  slight  external  influences,  as  well  as 
sensitive  or  painful  to  pressure,  we  should  enucleate  it 
at  once.  We  should  also  enucleate  the  eye,  even  if  it 
still  possesses  a  slight  amount  of  vision,  provided  that 
it  cannot  be  securely  guarded  from  noxious  influences, 
or  if  we  cannot  rely  upon  the  intelligence  of  the  pa- 
tient. But  if  the  patient  be  thoroughly  intelligent, 
we  can  point  out  to  him  the  various  symptoms  and 
circumstances  under  which  he  should  at  once  seek 
surgical  advice. 

As  soon  as  the  stage  of  sympathetic  irritation  has 
become  pronounced,  we  should  instantly  enucleate, 
even  if  the  injured  eye  still  preserves  vision.  In 
serous  iritis,  as  well  as  plastic  iritis  with  only  a  few 
adhesions,  we  should  never  enucleate,  but  keep  the  pa- 
tient under  the  most  guarded  regimen  :  rest  in  bed  in 


THERAPEUTICS.  205 

a  darkened  room,  regulation  of  the  diet,  together  with 
care  for  easy  evacuation  of  the  bowels.  Locally,  we 
should  resort  to  solutions  of  atropia.  If  the  eye  is 
painful,  and  the  circumcorneal  injection  well  pro- 
nounced (which  conditions  are,  however,  very  rare  in 
iritis  serosa),  we  should  try  bloodletting  at  the  tem- 
ples, as  well  as  poultices  applied  to  the  eye.  Weeks, 
or  even  months  later,  when  the  iritis  has  wholly  disap- 
peared we  may  enucleate  as  a  preventive  of  future 
evil,  in  case  the  exciting  eye  has  not  become  wholly 
free  from  pain.  If  the  inflammation  has  culminated 
in  posterior  adhesions,  with  bulging  of  the  peripheral 
portions  of  the  iris,  and  subsequent  secondary  glau- 
coma, we  cannot  rely  upon  the  usual  anti-glaucorna- 
tous  remedies,  such  as  eserin  sulphate,  pilocarpin  mu- 
riate (in  one  per  cent,  solutions),  but  we  must  try  to 
restore  the  communication  between  the  two  chambers 
by  an  iridectomy. 

Genuine  plastic  irido-cyclitis  demands,  of  course, 
the  above-mentioned  strictness  of  regimen,  and  the 
most  abundant  patience,  as  well  on  the  part  of  the 
surgeon  as  of  the  sufferer.  Bloodletting  and  atropia 
seem  to  do  more  harm  than  good  in  this  type  of  the 
disease.  "We  can  best  resort  to  repeated  poultices, 
and  (if  necessary)  to  morphia  injections.  If  the  pa- 
tient consents,  we  may  try  acute  mercurialization,  aim- 
ing to  saturate  the  system  with  mercury  in  the  shortest 


206  SYMPATHETIC   DISEASES    OF   THE   EYE. 

possible  time.  For  this  purpose,  from  six  to  ten 
grammes  (  3  iss.-  3  iiss.)  of  gray  mercurial  ointment 
should  be  rubbed  in  daily,  conjoining  this  treatment 
with  the  internal  exhibition  of  calomel  in  one  to  two 
decigramme  doses  (grs.  iss.-iij.)  every  two  hours  until 
salivation  is  produced.  But  inasmuch  as  irido-cyclitis 
rarely  leads  precipitately  to  unfortunate  results,  a  com- 
mon well-regulated  course  of  inunction  seems  to  me 
altogether  more  suitable.  We  ought  to  try  this  treat- 
ment in  order  to  satisfy  our  consciences.  But  we  should 
not  expect  too  flattering  results.  If  we  carefully 
analyze  the  few  reported  cases  of  rapid  and  perfect 
cure  effected  by  acute  mercurialization  after  previous 
enucleatiori,  we  shall  discover,  without  the  shadow  of  a 
doubt,  that  the  cases  were  not  genuine  irido-cyclitis, 
and  that  therefore  this  type  of  disease  was  not  cured 
by  mercury.  Nor  can  we  attribute  any  decidedly  favor- 
able influence  to  the  enucleation.  This  operation,  by 
the  way,  we  can  omit  with  a  calm  conscience  under 
the  circumstances  here  mentioned.  The  sympathetic- 
ally affected  eye  may,  if  it  has  not  become  blind,  be 
subjected  to  an  operation  at  a  future  time. 

"We  Have  now  finished  our  account  of  the  therapeu- 
tical measures  which  may  be  adopted  in  the  severest 
forms  of  sympathetic  ophthalmia  (affections  of  the 
uveal  tract),  but  we  have  yet  to  say  something  of  the 
remedies  which  may  be  employed  in  the  secondary  or 


THERAPEUTICS.  207 

minor  forms  of  this  insidious  affection.  Sympathetic 
retinitis  or  neuro-retinitis,  which  ensues  in  company 
with  inflammations  of  the  uveal  tract,  cannot,  on  the 
whole,  have  any  influence  in  inducing  us  to  change  our 
indications  for  operative  interference,  notwithstanding 
the  few  reported  cases  of  sympathetic  keratitis  and 
scleritis  have  always  been  known  to  disappear  after 
enucleation.  This  form  of  sympathy  should  be  treated 
by  rest,  darkness,  bloodletting,  inunctions,  and  the 
iodide  of  potassium.  Shall  we  enucleate  if  it  is  diag- 
nosticated as  being  independent  of  any  uveal  affec- 
tion ?  I  am  of  the  opinion  that  sympathetic  neuro- 
retinitis  is  due  to  a  similar  morbid  process  in  the  oppo- 
site optic  nerve  and  retina.  Inasmuch,  therefore,  as 
the  division  of  an  inflamed  nerve  does  not  seem  any 
too  seductive  to  me,  and  as  a  relatively  great  number 
of  these  cases  have  been  observed  directly  after 
enucleation  (showing  that  the  deleterious  influence  of 
the  division,  or  of  the  cicatrix,  upon  the  nerve  can 
hardly  be  denied),  I  would  not  like  to  enucleate  in 
a  case  of  sympathetic  neuro-retinitis,  despite  those 
favorable  results  which  have  been  reported.  Several 
cases  of  sympathetic  retinitis  were  reported  at  the  In- 
ternational Ophthalmological  Congress,  in  New  York 
(1876),  by  Alt,  Derby,  and  Bisley.  Alt  saw  rapid  im- 
provement and  recovery  after  enucleation  in  one  of 
his  three  cases.  But  it  seems  to  me  that  the  sympa- 


208  SYMPATHETIC   DISEASES   OF   THE  EYE. 

thetic  origin  of  these  cases  was  not  accurately  demon- 
strated, for  the  optic  nerve  of  the  enucleated  staphy- 
lomatous  eye  showed  deep  glaucomatous  excavation 
and  atrophy.  Moreover,  several  observers  besides 
myself  have  seen  a  sympathetic  retinitis  disappear 
spontaneously,  under  suitable  circumstances. 


INDEX, 


A  BSCISSION  of  cornea  as  a  substitute  for  enucleation,  188 
~^^    Accommodation,  16 

asthenopia  of,  62 
impairment  of,  68 
Amblyopia,  sympathetic,  97 
Anaesthesia  of  retina,  66,  128 
"         sympathetic,  105 
Anaesthetics  during  enucleation,  176,  177 
Anatomy  of  ciliary  nerves,  57,  58 

"  eye,  12 

Anterior  capsule,  13 

"         incarceration  of,  in  wound  of  eye,  42 
"        chamber,  13 
Aqueous  humor,  13 

"        imprisonment  of,  behind  iris,  78 
"        normal  means  of  escape  of,  77 
Artificial  eyes,  description  and  mode  of  adaptation  of,  150,  151 

"      as  cause  of  sympathetic  ophthalmia,  51,  70, 134,  136, 151 
Atrophic  choroiditis,  86,  92 
Atrophy  of  ciliary  nerves,  119 
"  eye,  28 

"          optic  nerve,  119,  128 
Atropia,  196,  203 


~O  AND  AGE,  compress,  175 

Blepharoraphy  as  a  substitute  for  enucleation,  188 
Blepharospasm,  59 

Blindness,  total,  from  repetition  of  original  injury,  9 
Blood  effused  into  retina,  88 
Blows  on  eye,  25,  52 


210 

/^ANAL  of  Fontana,  16 
^      "  Schlemm,  16 

Capsule  of  Tenon,  150 
"         lens,  13 

u  "      shrivelling  of,  42 

Case  of  arrow-wound  of  eye  (Mauthner),  21 

"      bit  of  iron  encapsuled  nine  years  in  ciliary  muscle  (Bowen),  24 
"      metal  lodged  seventeen  years  in  optic  nerve  (Bowen),  25 
"      cataract  operation  producing  sympathy  (Mauthner),  39 
"      double  operation  for  cataract  (Knapp),  41 
"      enucleation  after  linear  extraction  of  cataract  (Mauthner),  39 

for  iritis  serosa  (Mooren),  154 
"  "  "          "       (Derby),  154 

"  "  "          "       (Knapp),  155 

"       refused  by  patient  (Samelsohn),  156 
"  with  unsuccessful  result  (Gayet),  165 

*'      haemorrhagic  glaucoma  (Pagenstecher),  100 
"      herpes  zoster  ophthalmicus  producing  sympathy  (Jeffries),  44 

(Noyes),  44 

"  horse  bite  of  eye  producing  sympathy  (Mauthner),  29 
"  injury  of  ciliary  body  from  bit  of  iron  (Mauthner),  18 
"  "  eye  by  a  cramp-iron  (Mauthner),  193 

"  "          "    from  a  bit  of  glass  (Mauthner),  23 

"      iridodesis  producing  sympathy  (A.  Graefe),  35 
"  "  "  "          (Steffan),  36 

"      leech  bite  of  eye  producing  sympathy  (Lebrun),  30 
"      lodgment  of  bit  of  metal  in  posterior  chamber  (Mauthner),  19 
"      neurotomy  for  sympathetic  neuro-retinitis  (Rheindorf),  178 
"      peri-neuritis  of  optic  nerve  producing  sympathy  (Mooren),  132 
"      persistent  photopsies,  despite  enucleation  (A.  Graefe),  65 
"      poliosis  arising  from  sympathy  (Shenkl,  Jacobi),  85 
"       primary  lesion  of  optic  nerve  (Brailey),  126 

"        neuro-retinitis  (Williams),  126 
"      resection  of  stump  of  optic  nerve  after  enucleation  (Derby), 

154 

'•      reunion  of  nerves  after  neurotomy  (Mauthner),  185 
u      sudden  death  associated  with  a  proposed  iridectomy  (Trans- 
lators), 148 

"      sympathetic  choroido-retinitis  (v.  Graefe),  87 
«i  u  «>  u  u         88 

"  "         contraction  of  field  of  vision  (Brecht),  67 

"         ophthalmia  after  recovery  from  cyclitis  (Mauth- 
ner), 52 

"      sympathetic  ophthalmia  from  enucleation  (Colsmann),  93 
"  "  "  "  "  (Mooren),  94 


INDEX.  211 

Case  of  sympathetic  ophthalmia  from  enucleation  (Miiller),  94 
"  "  "         ,    "  (Vignaux),  158 

"    gunshot  wound  (Cohn),  49 
"      wound  of  eye  by  a  cow's  horn,  producing  sympathy  (Mauth- 

ner),  136 

Cataract,  cases  of  cyclitis  after  operations  for,  39,  40,  41 
u        causes  of  original  irritation  in  eyes  treated  for,  42 
"        depression  (or  reclination)  of,  37 
"        division  of,  37 
"        extraction  of,  37 
44        flap  operation  for,  38 
44        lamellar,  32 

44        modified  linear  extraction  of,  39 

"        operations  for,  causes  of  sympathetic  ophthalmia,  31,  39,  103 
44        stationary  central,  31 
14        sympathetic,  102 

Cellular  plate  of  ligamentum  pectinatum  iridis,  13 
Chiasma,  relations  of  optic  nerves  at,  106 
Choroid,  15 

44        peculiar  form  of  morbid  patches  in,  8G 
Choroidal  sarcoma,  43 
Choroiditis,  28 

atrophic,  86 

purulent,  production  of,  as  a  substitute  for  enucleation,  186 
Choroido-retinitis,  87,  88 
Ciliary  body,  15 

44        44        detachment  of,  42 

44        41        diseases  of,  17 

44        "        foreign"  objects  encapsuled  in,  24 

44        4l        injuries  of,  17,  23,  25,  26,  42,  65 

44        "  44         spontaneous  cure  of,  17,  18 

44         symptoms  and  anatomical  changes    caused 
by,  26 
ganglion,  58 
44      muscle,  15 
44      nerves,  anatomy  of,  57,  58 

41        as  conductors  of  sympathy,  110-120 
44        atrophy  of,  119 

44        composition  and  functions  of,  57,  58 
4 '        reunion  of,  after  neurotomy,  182 
44      neuralgia,  63 
Circle  of  Willis,  109 
Compress  bandage,  175 
Cornea,  13 

14      abscission  of,  as  a  substitute  for  enucleation,  188 


212  INDEX. 

Cornea,  curvature  of,  impaired  by  iridodesis,  34 

"       paracentesis  of,  193 

"       phlyctenulae  of,  59 

u       staphyloma  of,  45,  46 

Creed  (Mauthner's)  prescribing  and  limiting  enucleation,  170 
Crystalline  lens,  12 
Cyclitis,  26,  29 

"        acute,  Mooren's  definition  of,  29 
Cyclo-choroiditis  as  a  cause  of  sympathetic  ophthalmia,  46 
Cysts  of  iris  as  a  cause  of  irido-choroiditis,  43 
Cysticerci,  intra-ocular,  43 


T^EATH,  after  enucleation,  147,  160 
Descemet's  membrane,  13 

deposits  on,  in  serous  iritis,  74 
Detachment  of  retina,  38,  103 

ciliary  body,  43 

Diagnosis  of  sympathetic  ophthalmia,  144 
Diffused  light,  disturbance  of  vision  by,  33 
Diseases,  sympathetic,  list  of,  56 

relative  severity  of,  103 

Drainage  of  eye,  as  a  cause  of  sympathetic  ophthalmia,  104 
u        operation  of,  described,  103 


~Cp  ABLIEST  advent  of  sympathetic  ophthalmia,  142,  143 
Enucleation,  accidents  from,  147,  149,  153,  159 
"  after-treatment  of,  1 75 

anaesthetics  during,  176 
"  as  a  cause  of  death,  147,  160 

"  "         "        disfigurement,  149,  151 

"         "        sympathetic  ophthalmia,   51,    63, 
132,  155 
"  creed  indicating  and  contraindicating,  170 

crushing  of  optic  nerve  during,  163 
"  indications  for  and  against,  163-170,  202-206 

"  in  irido-cyclitis,  169 

"    iritis  maligna,  159 
"  u        i.    piagfcjca^  168 

"  "         "     serosa,  167 

"  "    panophthalmitis,  160 

"  of  left  eye,  171 

"  right  eye,  175 
"  "  wrong  eye,  175 


INDEX.  215 

T  ENS,  crystalline,  12 
"        dislocation  of,  34 

as  a  cause  of  irido-choroiditis,  43 
Ligament,  suspensory,  12 

laceration  of,  34 

Ligamentum  pectinatum  iridis,  13 
Linear  extraction  of  cataract,  39 

"  "  "         causing  sympathetic  ophthalmia,  41,  103 


"A/TEMBRANE  of  Descemet,  13 

•"•*•         "  "  deposits  on,  in  serous  iritis,  74 

Mercury  in  sympathetic  ophthalmia,  196,  202,  205 

Motion  of  artificial  eye,  150 

Motor  fibres  of  ciliary  nerves,  58 

"VTEOPLASM  attached  to  optic  papilla,  22 
Nerves,  ciliary,  anatomy  of,  57,  110 

41        as  conductors  of  sympathy,  110-120 
"        atrophy  of,  119 
Nerve,  naso-ciliary,  57          • 
"      optic,  14 

"          "      as  conductor  of  sympathy,  110,  118,  120,  122 
"          "      atrophy  of,  119 

"          "      excavation  of  intra-ocular  end  of,  97 
"          "      hyperplasia  of  intra-ocular  end  of,  65 
Neuralgia,  ciliary,  63 
Neuro-retinitis,  sympathetic,  133 

"        "  "  treatment  of,  207 

Neurotomy,  177 

f          "  as  a  preventive  of  sympathetic  ophthalmia,  186 

"  ciliary,  181 

extra-ocular,  180 

general  remarks  on,  181 
"  "  history  of,  177 

method  of  performing,  183,  184 
reunion  of  nerves  after,  182 
"  intra-ocular,  178,  181 

/^\BLIQUE  illumination  of  eye,  72 
^^^     Occlusion  of  pupil,  76 
Optico-ciliary  neurotomy,  180 
Optic  nerve,  14 

"          "      as  conductor  of  sympathy,  65,  108,  121,  126,  130,  132 


216  INDEX. 

Optic  nerve,  atrophy  of,  119,  128 

"          "      excavation  of  intra-ocular  extremity  of,  95,  97 

"          "      mode  of  crossing  of,  at  chiasma,  106 

"          "      sympathetic  affections  of,  92 

"      papUla,  14 
Ora  serrata,  14 
Orbital  cellulitis  after  enucleation,  149 


TDANOPHTHALMITIS,  47,  147,  203 

"  enucleation  during,  160 

Paracentesis  of  cornea,  193 
Pars  ciliaris  retinae,  1 09 
Pathogeny  of  sympathetic  ophthalmia,  105 
Pathology  of  sympathetic  ophthalmia,  56 
Phlyctenulae  of  cornea,  scrofulous,  59 
Photophobia,  59,  64,  128 
Photopsia,  59,  64,  128 
Phthisis  of  eye,  23,  100 
Pigment  spots  in  retina,  89,  92 
Pilocarpin,  muriate,  205 
Plastic  iritis,  75,  80,  157,  168,  191 
Poliosis,  sympathetic,  85 
Posterior  capsule,  12 
"        chamber.  14 
Poultice-papers,  Lelievre's,  203 
Preliminary  remarks,  10 
Pressure  points,  84,  85,  113,  195 
Prognosis  of  sympathetic  ophthalmia,  145 
Pupil,  exclusion  of,  76,  192 
"      occlusion  of,  76 


QUESTION  of  enucleation  in  sympathetic  ophthalmia  discussed, 
146-177 
Question  of  neurotomy  in  sympathetic  ophthalmia  discussed,  177-186 


"OEFLEX  action  in  conduction  of  sympathy,  112 

Refracting  media  of  eye,  12 
Retina,  14 

"       anaesthesia  of,  66,  128 

"        detachment  of,  28,  103 

u        hasmorrhagic  extravasations  into,  50,  88 

"       hypersesthesia  of,  62,  66,  68,  128 


INDEX.  217 


Retina,  irritation  of,  62 
"       pars  ciliaris  of,  109 
"       pigment  spots  in,  89,  93 

Retinal  gliomata,  43 

Retinitis,  sympathetic,  87-92 

^  "  treatment  of,  207 


C  ARCOMA.  of  choroid,  43 

Schlemm's  canal,  16 
Solera.     See  Sclerotica. 
Sclerotica,  13 

softening,  or  relaxation  of,  45 
staphylomata  of,  45,  46 
Scleritis.  See  Sclerotitis. 
Sclerotitis,  71,  207 
Sclerotomy,  193,  197 
Serous  iritis,  71,  75,  80,  102,  167,  190 
Sight,  impairment  of,  without  structural  lesion,  66 

"      restored,  of  first  eye,  jeopardized  by  operation  on  other  eye,  41 
Staphyloma  of  cornea,  45 
Staphylomata  of  sclerotica,  45,  46 
Strieker's  experiments,  110 
Suspensory  ligament,  12 

Symmetrically  painful  points  on  eyeballs,  84,  85,  113,  195 
Sympathetic  anaesthesia,  105 

"          atrophy  of  optic  nerve,  92 

"          cataract,  102 

kl          choroiditis,  86 

"          choroido-retinitis,  88 

"          cicatrix,  105 

"          diseases  of  eye,  varieties  of,  56 

"  "        relative  severity  of,  80,  102 

"          fibres  of  ciliary  nerves,  58 
"          glaucoma,  95-101 

"  acute,  99 

hsemorrhagic,  100 

without  inflammatory  symptoms,  9b 
"          iritis,  from  enucleation,  82,  93 

"       maligna,  80 
"  "         mode  of  propagation  of,  107 

u      plastica,  76  et  seq. 
"  "      serosa,  71  el  seq. 

"  irritation,  58-67 

"  "          after  foreign  bodies  in  eye,  59 


3  L8  INDEX. 

Sympathetic  irritation,  as  affected  by  enucleation,  166 

"          causes  of,  61 

"  "          condition  of  second  eye  in,  62 

44  "         diflFerent  forms  of,  59,  60 

"         of  optic  nerve,  64,  65 
"         of  retina,  63,  64,  66 
44          removed  by  suppurative  choroiditis,  186 
"          with  limitation  of  field  of  vision,  67 
"      impaired  vision;  6b' 
"      phlyctenulae,  59 
44          keratitis,  48,  70,  307 
"          opacities  of  vitreous  humor,  102 
44          poliosis,  85 
"          retinitis  pigmentosa,  93     : 
44          aclerotitis,  71,  207 
14          ophthalmia,  after  recovery  from  cyclitis  Without  atrophy 

of  eyeball,  52-55 

u          ophthalmia,  diagnosis  of,  144 
"  ".          definition  of,  10 

_  "  from  artificial  eye,  51,  70,  134,  151 

44   atrophy  of  optic  nerve,  92 
"    bit  of  iron  encapsuled  nine  years  in  cil- 
iary muscle,  24 
44    bit  of  metal  lodged  seventeen  years  in 

optic  nerve,  25 

1 '    cerebro-spinal  meningitis,  44 
"  "  "    cyclo-choroiditis,  46 

"  "    cysticerci,  43 

"  "    detachment  of  retina,  47 

•'  "    drainage  of  eyeball,  104 

44  "  "    enucleation  of  eye,  51,  62,  93,  132,  155 

44  "  "    glaucoma,  46 

"  "    glioma  of  retina,  43 

"    gonorrhoeal  ophthalmia,  50 
44  "  '4    gunshot  wounds,  49 

"    haemorrhage  into  vitreous  humor,  47 
"    herpes  zoster  ophthalmicus,  44 
44  "  "    horse  bite,  29 

44  u  4t    iridectomy,  42 

14  "  4l    irido-cyclitis,  43 

"  "  "    iridodesis,  35,  103 

44  "  "    leech  bite,  30 

*4  "  •  mechanical  injuries  of  ciliary  body,  48 

"    operations  for  cataract,  31,  39,  103 
44     panophthalmitis,  47,  161 


INDEX.  219 

Sympathetic  ophthalmia  from  prolapse  of  iris,  48 

44    sarcoma  of  choroid,  43 
14    syphilis,  44 
44    ulcers  of  cornea,  45 
44          exsection  of  optic  nerve  in,  189,  154 
"          iridectomy  in,  189 
"          medical  treatment  of,  202 
"          relative  frequency  of,  in  the  various  cataract 

operations,  41 

"'          relative  frequency  of  traumatic  agencies  pro- 
ducing, 26 

"  44          time  of  appearance  of,  141 

44          without  cyclitis,  51 
44  "       disease  of  uveal  tract,  51 

44       injury  of  ciliary  body,  50 
Sympathy,  means  and  methods  of  transmission  of,  105,  132,  138 

transmitted  by  the  ciliary  nerves,  110,  111,  115,  117,  118, 

120,  139 

transmitted  by  the  circle  of  Willis,  109 

44  44  by  the  optic  nerves,  1C6, 117,  119,  127,  140 

44  44  by  reflex  action,  120,  125 

rpENON'S  capsule,  150 

Tension  of  eye,  definition  of,  21 
Therapeutics  of  sympathetic  ophthalmia,  146 
Transmission  of  sympathy  by  ciliary  nerves,  110-120 

44  44  circle  of  Willis,  109 

44  "  optic  nerves,  65,  108,  121,  126,  130,  133 

Traumatic  complications,  in  diseases  of  ciliary  body,  17 
Tunics  of  eye,  12 

TTLCERATIVE  process  permitting  prolapse  of  iris  or  of  ciliary 

body,  45 
Uveal  tract,  15 

14        44      acute  purulent  diseases  of,  46,  47 

44        '4      idiopathic  affections  of,  43 

44        44      mechanical  irritation  of,  43 


"YTISION,  impairment  of,  without  anatomical  changes,  66 

u        restored,  of  first  eye,  endangered  by  operation  on  second,  41 
Vitreous  humor,  12 

"  '*        filamentous  opacities  of,  102 

44  "        molecular  opacities  of,  88 


220  INDEX. 

"TTTILLIS,  circle  of,  109 
*  •       Wounds  of  ciliary  body,  17 
"         eye,  arrow,  21 
"  "    gunshot,  49,  50  6S 


-y 


ELLOW  spot,  15 


ONULA  of  Zinn,  12 

u  "          laceration  of,  '-' 


THE  EM>. 


Date  Due 


PRINTED   IN   U.S.A.  CAT.      NO.     24      161 


,.!£?.?.U™.™  REGIONAL  LIBRARY  FACILIT 


A     000510444     3 

4 


WW525 


1881 
Mauthner,  Ludwig. 

The  sympathetic  diseases  of  the 
eye 


WW525 


1881 
Mauthner,  Ludwig. 

The  sympathetic  diseases  of  the  eye 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


